Interventions for Mental Health. An Evidence-Based Approach for Physiotherapists and Occupational Therapists

296 Pages·2003·4.824 MB·English

by  Tina Everett, MSc MCSP, Marie Donaghy, PhD BA(Hons) FCSP ILTM, and Sally Feaver, MABA DipOT (Eds.)

BUITERWORTH-HEINEMANN
An imprint of Elsevier Science Limited
© 2003, Elsevier Science Limited. Allrights reserved.
No part of this publication may be reproduced, stored ina retrieval system, or transmitted in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise,
without either the prior permission of the publishers or a licence permitting restricted copy
ing in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court
Road, London WIT 4LP. Permissions may be sought directly from Elsevier's Health Sciences
Rights Department in Philadelphia, USA: phone: (+I) 215 238 7869, fax: (+l) 215 238 2239,
e-mail: [email protected]. You may also complete your request on-line via the
Elsevier Science homepage (http.Z/www.elsevier.com), by selecting 'Customer Support' and
then 'Obtaining Permissions'.
Firstpublished 2003
ISBN07506 4965 8
BritishUbraryCataloguingin PublicationData
Acatalogue record for this book isavailable from the British Library
libraryofCongressCatalogingin PublicationData
Acatalog record for this book isavailable from the Libraryof Congress
Notice
Medical knowledge isconstantlychanging. Standardsafety precautions must be followed,
but as new research and clinical experience broadenour knowledge, changes intreatment
and drug therapy may become necessary or appropriate. Readers are advised to check the
most current product information provided by the manufacturerof each drug to be adminis
tered to verify the recommended dose, the method and duration of administration, and con
traindications. It isthe responsibility of the practitioner, relying on experienceand
knowledge of the patient, to determine dosages and the best treatment for each individual
patient. Neither the Publisher nor the editorsand contributors assumes any liabilityfor any
injury and/or damage to personsor propertyarising from this publication.
The Publisher
yoursourceforbooks,
journalsandmultimedia
. . inthehealthsciences
www.elsevierhealth.com
The
publisher's
policyistouse
Cover design based on an original idea by Lee Haynes papermanufactured
fromauatalnableforeata
I
Printed inChina
Contributors
DianaBeaven Grad Dip Phys
Senior Physiotherapist, Barrow Hospital, Bristol, UK
PatsyBrodie Dip COT
Head of Occupational Therapy Service Adult Mental Health, Royal
Dundee LiffHospital, Dundee, UK
Helen Burl MScPGCert LTDip COT
Senior Lecturer, Sheffield Hallam University, Sheffield, UK
David Carless MScBA
Researcher in Exercise and Health Science, University of Bristol,
Bristol, UK
Sarah Childs BOcc THE
Head IVOccupational Therapist, Rehabilitation and Continuing Care,
Fair Mile Hospital, Cholsey, Berkshire, UK
AndrewClyne Grad Dip Phys
Senior Physiotherapist, Adult Mental Health Service, Swindon, UK
NicolaConnolly D Clin Psych MABA
Clinical Psychologist, Highfield Adolescent Unit Warneford Hospital,
Oxford, UK
Shelagh Creegan BSc(Hons) Health Studies, Dip COT
Head Occupational Therapist, Adult Mental Health, The Community
Workshop, Dundee, UK
JenniferCreek MScDip COT FETC
Freelance Occupational Therapist
Pam Dawson PhD PGCED MCSP
Principal Lecturer in Allied Health Professions Research, Newcastle
upon Tyne, UK
Marie Donaghy PhD BA(Hons) FCSPILTM
Head of School, Health and Biological Sciences, Queen Margaret
University College, Edinburgh, UK
Jonquil Drinkwater PhD AFBPsS
Head of Child and Adolescent Psychology, Oxfordshire Mental
Healthcare Trust, Oxford, UK
vii
viii Contributors
EdwardASDuncan BSc (Hons) Dip CBTSROT
Senior Occupational Therapist, The State Hospitals Board for Scotland,
Carstairs, Lanark, UK
Tina Everett MScMCSP
Head Physiotherapist for Oxfordshire Mental Healthcare NHSTrust,
Warneford Hospital, Oxford, UK
Alice Farrington DClin Psych
Clinical Psychologist, The Park Hospital for Children, Headington,
Oxford, UK
Guy Faulkner BEd MScPhD
Lecturer in Exercise and Sports Psychology, University of Exeter,
Exeter, UK
SallyFeaver MABA DipOT
Principal Lecturer, Oxford Brookes University, Headington, Oxford, UK
Kenneth Fox BSc MScPhD
Professor and Head of Department of Exercise and Health Sciences,
University of Bristol, Bristol, UK
Colin Godfrey RGN SPSA
Activities Development Nurse for Oxfordshire Mental Healthcare NHS
Trust, Oxford, UK
Caroline Griffiths MCSP Grad Dip Phys
Clinical Specialist Physiotherapist, Northamptonshire Healthcare Trust,
Northampton, UK
John Hall PhD FBPsS Clin Psychol
Head Clinical Psychologist for Oxfordshire Mental Healthcare NHS
Trust and Senior Clinical Lecturer in Clinical Psychology, University of
Oxford, Oxford, UK
GitaIngram Dip COT SROT
Senior Occupational Therapist, Royal Hospital for Sick Children,
Edinburgh, UK
DerekJones BA(Hons) Dip COT SROT
Lecturer in Occupational Therapy, Queen Margaret University College,
Edinburgh, UK
Mary Kavanagh MScBA(Hons) Dip COT SROTCert. Couns,
Lecturer in Occupational Therapy, Oxford Brookes University,
Headington, Oxford, UK
Denis Martin DPhil MSc(Applied Statistics) BSc (Hons) MCSP Grad Stat
Director Scottish Network for Chronic Pain Research, Queen Margaret
University College, Edinburgh, UK
Louise Montague-Jones Dip COT SROT/Cert THE
Senior Occupational Therapist, Oxfordshire Mental Healthcare NHS
Trust, Oxford, UK
Conceptual frameworks for community careand working with carers ix
Nanette Mutrie OPE, MEd PhD
Professor of Physical Activity and Health Science, University of
Glasgow, Glasgow, UK
Margaret Nicol Dip COT MPHILPhD
Acting Head of Department, Occupational Therapy and Art Therapy,
Queen Margaret University College, Edinburgh, UK
GwynethOwen MScMCSP
Professional Advisor, Chartered Society of Physiotherapy, London, UK
Catherine Pope MAMCSP
Physiotherapy Manager, Nottinghamshire Healthcare NHSTrust,
Nottingham, UK
NickRose MBChB MAFRC Psych
Consultant Psychiatrist and Honorary Senior Lecturer, University of
Oxford, Oxford UK
Mick Skelly MScMCSPDip Phys Dip AD SRP
Superintendent Physiotherapist, Rosslynlee Hospital, Roslin,
Midlothian, UK
Unette Whitehead BA MSc(Oxon)
Consultant Clinical Psychologist, Warneford Hospital, Oxford, UK
Emma Williams BSc(Hons) MPhii (Clin Psychol) PhD
Consultant Clinical and Forensic Psychologist, Oxford Mental
Healthcare NHSTrust, Oxford, UK
Foreword
Physiotherapy as a therapeutic intervention in the management of people
with mental illhealth has come a long way since itssmall beginnings in the
1970s. It is now part of the central core of the profession, helping to fur
ther broaden the boundaries and scope of physiotherapy. Occupational
therapy has a much longer history, almost since the inception of the pro
fession in 1937 (in Scotland), occupational therapists have been providing
a central therapeutic role in the rehabilitation and management of people
with mental illhealth. Both disciplines are still advancing with the applica
tion to practice of the emerging evidence and the desire for more collab
orative working. These wide developments are well covered in this text
book, based on the solid evidence-base of real benefits to clients and the
pioneering techniques that show promise for the future in treating partic
ular conditions.
Mental health is a key priority for the modern NHS and social services.
This is unsurprising considering that depressive disorders are the fourth
most important cause of disability worldwide. In the UK, anxiety and
depression are one of the major sources ofvisits to GPs, make a large com
ponent of the primary care drugs bill and result in over 80000 working
days lost annually, at a cost of at least £5.3 billion. The total cost of treat
ment in both primary and secondary care is huge. It is therefore unsur
prising that governments have a major interest in care solutions that can
help to improve mental health in its varied forms.
This is why mental health is an exciting and evolving area of work for
physiotherapists and occupational therapists. It focuses on the reality that
the mind and the body are one - they are not distinctive entities. People
can become clinically depressed as a result of a physical disorder or those
who have a mental disorder can develop a physical disorder as a conse
quence. The physical image of themselves that people with eating disor
ders have can be radically different from that of the rest of the world.
Anxiety, depression or addictive behaviour can be heavily influenced by
physical factors, self confidence or awareness.
As this book illustrates, physiotherapists and occupational therapists
working in mental health are uniquely placed to provide an extensive
range of physical approaches to treatment aimed at relieving symptoms,
boosting confidence and improving quality of life. Interventions include
physical activity, exercise and sport, balance, postural and movement edu
cation, useful occupation, creative therapy, achieving goals and life skills,
management ofchronic or acute pain, relaxation techniques, manual ther
apies, acupuncture and complementary therapies.
xii Foreword
Available evidence suggests that exercise, training and increased goal
oriented physical activity produce definite improvement in reducing
depression and anxiety, improved physical status, bettercognitive function
and can facilitate hehavioural lifestyle changes. The enormous expansion
of private gyms and sport facilities in the UKis testimony to the extent to
which physical activity as a stress reducer has become accepted hy the
wider public.
More broadly, physiotherapists and occupational therapists are also
involved in advice, guidance and education of users, carers and staff. The
promotion of self confidence and self awareness, motivation and social
ization are important components in this armoury. Increasing evidence
suggests that interventions such as cognitive-behavioural therapy, coun
selling and exercise can reduce anxiety and depression and enhance psy
chosocial function either as an adjunct to therapy or as an alternative
intervention. The psychological benefits of exercise in dealing with alco
hol and other addictions is becoming better known.
The occupational therapist and physiotherapist in mental health are
team players in a wider interdisciplinary team of social workers, psychol
ogists, nurses and others. To this teamworking, occupational therapists and
physiotherapists hringa breadth ofassessment and treatment expertise that
is often delivered alongside prescribed pharmacological or psychological
interventions. This new texthook, written hy experts in the field of mental
health therapy, can only help to expand the horizons of the possible in
improving mental health in the UK.
Phil Gray 2003
Introduction
The decision to write a new book for physiotherapists and occupational
therapists working in mental health, rather than update the previous book
Physiotherapy in mentalhealth: a practicalapproach (Everett et al 1995)
was taken to reflect current changes and trends in the delivery of services
for people with mental health problems. These changes include the need
to provide evidence-based interventions and the need for greater involve
ment of both physiotherapists and occupational therapists to promote and
share best practice. The need for an integrated approach is emphasized in
the standards of the National Service Framework for Mental Health and
in the NHS Plan. Throughout the book we have attempted to stress the
importance of working in partnership with the individual to whom we are
delivering the service, with primary care and specialist mental health
teams, voluntary agencies and social services. Wesupport the concept that
the person with mental illhealth should be placed at the centre of decision
making, with the therapist as enabler. We appreciate the need to promote
more interdisciplinaryeducation and teamwork while recognizing the chal
lenges that this can present.
The previous book evolved from the clinical interest group Chartered
Physiotherapists in Mental Healthcare providing a standard text, with a
global distribution, for physiotherapists working in this specialist field. This
new book has been written as a key text by and for occupational thera
pists and physiotherapists, with notable contributions from other health
care professionals, particularly clinical psychologists and academics in the
sport and exercise sciences. It is hoped that the book will be of value to
clinicians in other professions, particularly nursing and medical colleagues.
A growing number of skilled technical instructors with degrees in sport
and exercise science work within physiotherapy and occupational therapy
teams and it is envisaged that this book will be a useful text for them
also. The editors are very conscious of the fact that the authors are writing
from a British perspective and that named government initiatives are
mainly from the UK. However, attempts have been made to draw from
research worldwide, and it is the intention that the book will be of value
internationally.
Each chapter provides a description of the theoretical underpinning or
a critique of theoretical issues and an inclusion of the research supporting
the efficacy ofthe therapeutic intervention. It isourintention that this book
will provide physiotherapists and occupational therapists andstudents with
a scientific basis and an appropriate context in which decisions regarding
the selection of intervention can be made.
xiii
xiv Introduction
When considering applying the evidence presented within the text to
practice, it is important to distinguish between the efficacy of an interven
tion, i.e. the results achieved within the context of a therapeutic trial, and
clinical effectiveness, i.e. the results achieved in everyday clinical practice.
Research into therapeutic interventions involves a compromise between
providing rigorous procedures to implement and evaluate the intervention
and taking account of what normally happens during a therapeutic inter
vention, includingthe evolving and changing nature of the therapeutic rela
tionship. There is a tension between the need to achieve high internal
validity with an identifiable homogenized population and the extent to
which these findings can then be generalized to other clinical settings
where people with mental health problems differ in socioeconomic cir
cumstance, psychological and physical function. The context in which the
therapeutic intervention takes place also needs to be considered, particu
larly in relation to available resources that will impact on the frequency and
length of treatmentofferedand onthe quality of links with family and other
professionals and services. The ability of physiotherapists and occupational
therapists to provide a clinically effective service will be informed by an
understanding and interpretation of the research evidence considered
alongside a critical analysis of their own practice and the context in which
they operate.
The content of this book has been organized into three sections. Section
1 provides background knowledge and sets the book in context for the
reader. It includes: an introduction to mental disorder from different view
points (Chapter 1), definitions and diagnostic categories of mental disorders
including medical and psychological interventions (Chapter 2), the differ
ent contexts that inform the delivery of services including policy, service
evaluation and accountability (Chapters 3, 4 and 5).
Section 2 takes a thematic and principles-based approach, with the
emphasis firmly placed on activity and occupation. The intervention strate
gies presented were selected for their generic applicability across a range
of mental health problems. The reader is presented with evidence and
arguments to support the important role of physical self perceptions, in
relation to self-esteem and personal identity. This provides theoretical links
to the principles of and the evidence for physical activity as a legitimate
intervention strategy for people with mental health problems (Chapters
6-9). Chapter 10 is dedicated to cognitive-behavioural strategies, this
reflects the importance of this approach for occupational therapists and
physiotherapists and signals that this approach iscurrently being integrated
into a number of therapeutic interventions. Further chapters in this part of
the book provide the reader with specific examples of the application of
principles to deal with stress, aggressive behaviour and managing pain
(Chapters 11-13). This part closes with chapters on enabling occupation
and users' views on occupation (Chapters 14 and 15), stressing the impor
tance of this therapeutic intervention within the rehabilitation process.
The third and final section of the book brings together for the reader a
comprehensive knowledge ofspecific areas of physiotherapy and occupa
tional therapy practice. Some of the chapters in this section are defined by
population, for example children, adolescents and the elderly (Chapters 16
and 17), others are defined by nature of the specialist topic that is often
Introduction xv
associated with other symptoms and behaviours, for example eating disor
ders, chronic fatigue, sexual abuse and self harm (Chapters 21-24). These
topics should not be viewed in isolation but are recognized for their asso
ciation with other problems in mental health. Chapters 18, 19 and 20 intro
duce the reader to severe mental illness, forensic psychiatry and substance
abuse. The final chapter, entitled 'Employment for health' is included to
remind us that, for some people and their families, this isan importantgoal
(Chapter 25).The reality, however, isthatfor many people itwill be achiev
able but that for others it will not. For both physiotherapists and occupa
tional therapists, an understanding ofthe process will inform realistic goal
setting for other interventions
Some of the chapters contain case studies of clinical service user expe
rience - these examples are generally created from clinical experience
rather than being identified with one particular person. The names chosen
bear no relation to any particular individual. Quotes from service users
have either been published elsewhere or chosen anonymously from serv
ice audit. Identity has been hidden and, where necessary, permission has
been obtained.
Complementary therapies, although referenced in some ofthe chapters,
do not feature in this text. This is in recognition that complementary med
icine is now an established therapy in its own right with several key texts
published in this area.
This book is dedicated to Eirean Ricketts, a Fellow of the Chartered
Society of Physiotherapy and editor of the previous text for physiothera
pists, who sadly died ofcancer. Eirean was a pioneer physiotherapist from
Cardiffwho, through vision and hard work with her occupational therapy
colleagues, gained recognition for physiotherapy in the management of
people with mental health problems.
2003 Tina Everett
Marie Donaghy
Sally Feaver
Reference
Everett T, Dennis M, Ricketts E (eds) 1995 Physio
therapy in mental health: a practical approach
Butterworth Heinemann, Oxford
1 Models of mental health
disorder
Marie Donaghy
Introduction Models are defined, for the purpose of this chapter, as representations
of a particular body of knowledge, put forward as an explanation and
interpretation of events. They are intended to give the reader insight
into the application of different theoretical approaches to the clinical
setting. Numerous models inform the work of physiotherapists and
occupational therapists, and many of these are contained in other chap
ters of this book. Those selected for this chapter have been brought
together to illustrate how knowledge from medicine and psychology
provide different viewpoints of people with mental health problems
and ultimately the interventions they are engaged in or prescribe. The
biomedical and neurobiological models are presented alongside the
family therapy, humanistic, psychodynamic and cognitive-behavioural
models from psychology. Social models have also been developed to
challenge and reject the establishedviews of mental illness (Kovel 1982,
Laing 1967, Szasz 1961). These were discussed by the author in an ear
lier publication (Donaghy 1995) and are not included here because they
are perceived to be less relevant to the strategies currently used by
physiotherapists and occupational therapists in the management of peo
ple with mental health disorders.
Mental health Mental health disorders can be studied from two major standpoints: (1)
disorders how the brain works; and (2) from knowledge about how man inter
acts within the environment (Goldberg & Huxley 1992). The first
approach is from the biomedical perspective and considers the scien
tificdiscipline of the neurobiology of mental illness, including genetics.
The otherapproach comes from the social sciences and considers meth
ods of inquiry derived from epidemiology, sociology and psychology.
Areview of recent developments from the medical perspective suggests
that although there have been advances in the field of neurobiology,
progress is lagging behind other medical advances. The excitement
over the genetic breakthrough in schizophrenia and manic depression
in the 1980s has been replaced with the recognition that, to date,
3