Mental Health of Intellectual Disability- Occupational Therapy

Cathal Keaney shines a light on the Occupational Therapist’s profession in assisting people with Intellectual Disability and mental health issues on their journey to recovery and a better life, by identifying improvements that can be achieved in their environments.

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  • Occupational Therapists are concerned with the everyday activities people do as individuals, in families and with communities to occupy their time and bring meaning and purpose to life.
  • Occupational Therapists specialise in adapting and changing an individual’s environment to allow them to reach their potential.
  • A situation can occur where a person is excluded from engaging in things that have purpose to them.
  • People with intellectual disabilities are more likely to experience this.
  • People with an intellectual disability are among the most socially isolated and vulnerable groups in society. They are less likely to have jobs, less likely to own their own home and often rely on others for day-to-day support.
  • An MHID Occupational Therapist will focus on helping clients achieve their goals and participate productively in their lives.

In this article I will describe the role of the Occupational Therapist in the area Mental Health of Intellectual Disability. In the first section I will describe the concepts behind the profession, and then briefly describe some of the assessments used. This will be followed by the largest section which will include a description of the interventions with case study examples. Finally the conclusion will bring each of these strands together.

Key Concepts behind profession

Occupational Therapists are concerned with the everyday activities people do as individuals, in families and with communities to occupy their time and bring meaning and purpose to life. Human beings crave the ability to choose, organise and satisfactorily perform these actions that are culturally defined and are age-appropriate. Occupational Therapy empowers people to participate in the actions relevant to their lives. We identify an individual’s abilities and areas of difficulty in life, and consequently make a plan with the person and their family to achieve their goals utilising the identified skills and tackling the areas of difficulty. The environment we live in is crucial to all people and is an essential ingredient in achieving success and feeling fulfilled. For people with a mental health illness and intellectual disability, a rich environment is repeatedly a missing ingredient in their lives, and the obstacle that is preventing them from being successful and feeling fulfilled. Occupational Therapists specialise in adapting and changing an individual’s environment to allow them to reach their potential.

Townsend and Wilcock (2004) propose that Occupational Justice is based on the principle that participation in life is an individual right and being prevented from such participation is a form of injustice. Within our profession, this concept has contributed to a heightened awareness of injustices faced by many who are denied opportunities to participate in the aspects of life that interest them (Durocher, Gibson and Rapolt, 2014). Opportunities are often denied to people with mental illness and intellectual disabilities. Participation in meaningful activity leads to positive mental health and social inclusion. An ideal world is one “that would be governed in a way that enables individuals to flourish by doing what they decide is most meaningful and useful to themselves and to their families, communities and nations” (Stadnyk, Townsend and Wilcock, 2010, p. 330). The Occupational Justice framework also looks at the injustice of forced participation, where people are forced into activities that are not meaningful to them.

This injustice often leads to Occupational Deprivation – a situation where a person is excluded from engaging in things that have purpose to them. People with intellectual disabilities are more likely to experience this due to their dependence on others to plan and complete activities for them. While people with an intellectual disability need support in areas of their lives, they can be overlooked in decisions concerning their own lives. People with an intellectual disability are among the most socially isolated and vulnerable groups in society. They are less likely to have jobs, less likely to own their own home and often rely on others for day-to-day support. They are more likely to experience social deprivation and social isolation as well as being more likely to experience a range of health conditions including mental health problems and sensory impairment. We have a key role in helping people with mental health and intellectual disabilities to adapt their activity, environment or materials in the places they live and work. An Occupational Therapist’s multi-dimensional training puts us in a prime position to consider the range of difficulties people with an intellectual disability might experience. We work collaboratively with the client and their family to identify goals. People are happier when they are engaged in life’s activities and feel successful when engaged. Participation and choice are key components of our approach. We can help clients achieve in their life, and live it to their fullest capacity, which includes dealing with their constraints.

What do we do?

An MHID Occupational Therapist will focus on helping clients achieve their goals and participate productively in their lives, in the following areas:

  1. activities of daily living,
  2. work, and
  3. leisure interests.

How we do it?

Assessment

The MHID OT uses a clinical assessment process to identify their performance strengths & limitations, as well as environmental constrictions that are impeding their participation. An Occupational Therapist assesses how well a person moves, and how efficiently they think and problem-solve during activities of daily living. We also assess sensory impairment, lack of motivation, poor structure/routine and environmental constraints. The Occupational Therapist uses a variety of assessments during this process.

Intervention

In this section, I will give some examples of how I worked with MHID clients.

  • Skills development via 1-on-1 work with therapist, group work or consultation for those who support the person with an intellectual disability: I worked with a client with a moderate intellectual disability and a mental illness who lived at home with her parents. Her mental health had deteriorated to the point that she was spending all of her time at home and a significant proportion of her time in her bedroom. Following an assessment, I completed a 6-week 1-to-1 intervention in the home to develop cooking skills which the client had identified as an interest. I worked with her to develop her skills, to be more independent around the home domestically. The skill building process improved her self-esteem and consequently started her road to recovery. As we spent more time together she began to trust me. She became more confident. We started shopping together and now she is doing this shopping by herself in the supermarket. As a result of our work together, she has the confidence to engage in interests with her family including bowling, cinema and eating out in local restaurants. Recently she started attending an arts and crafts group in the local area one morning per week and has integrated well in the group. Her road to recovery continues.
  • Environmental adaptation to include the physical environment, sensory and social environment: Occupational Therapists are interested in how sensation affects a person’s ability to function. Sensation includes auditory, visual, smell, taste and touch. Staff referred a young woman in a residential group home because she was banging and kicking her bedroom door and they wanted an occupational therapy assessment to determine if this behaviour was a response to a sensory issue. A detailed sensory assessment identified that she was sensitive to certain noises including a humming noise made by another resident whose room was next to hers, which was causing her to bang and kick her bedroom door. I advised that she be moved to an alternative room and the distressing behaviour discontinued.
  • Support to develop meaningful occupations, facilitating motivation and promoting choice and control through activity: Occupational Therapists believe that offering choice and control reduces challenging behaviour and encourages more passive individuals to take a more active role in their lives. A man in his fifties with a mild intellectual disability was suffering from severe depression and challenging behaviour. He was spending 23 hours per day in his bedroom. I used his love of Manchester United and his interest in arts and crafts to engage with him. The client agreed to work with me for six weeks where we worked collaboratively to make a Manchester United lamp shade. His self-esteem improved, particularly when seeing the successful outcome of the lamp shade hanging in his room. Our collaboration continued with the making of a bird feeder which the client hung in his garden. His trust and confidence in me improved so much that I was able to encourage him to walk with me outside his house. Together we went to a coffee shop, library, cinema, bowling alley, GAA grounds and various walking tracks. At the appropriate time I encouraged him to access specific supportive social groups in the community. He is now a member of the local Special Olympics club and attends the bocce group once a week. At first I had to attend the club and meetings with him but now he is attending on his own. We then focused on becoming independent in the domestic skills of cooking, laundry and cleaning. Following this piece of work, he expressed the desire to live independently. He and his family made an application to the County Council for independent living, and I supported this process with a letter of support detailing the constraints of his current living environment and how it was affecting his mental health. He now lives by himself in a more purposeful environment with supports from the team and family support.
  • Work rehabilitation and development of vocational skills: A man in his late twenties with a moderate intellectual disability was diagnosed with depression. He was referred for vocational work. My assessment showed that he had a high skill level. He expressed a desire to have a job; however he never had paid employment. He completed some jobs for his neighbours but did not get paid very much and sometimes not at all. I could tell this was a frustration to him as he knew he was completing the jobs to a high standard. I met with Employability, the local employment agency for people with a disability. I provided a detailed written report and verbal description of his skills and motivation levels to the Employability jobs coach, and we discussed the various types of work which would best suit him best.  The jobs coach was successful in finding a job for him and he is thriving in his new job. His new employer is extremely happy with his work. In the initial phase of his new job, I supported and developed his time management skills to ensure he got to work at the correct time. This job has provided him with structure to his week, and he is now a paid employee for the first time in his life. This has had a very positive effect on his self-esteem and mental health.  
  • Developing structures and routines: to create a sense of control and predictability in the day helps orientate people to time and support independence. A young man with Autism and hypersensitivity was referred to me. My assessment showed me that during the day he became overstimulated due to too much noise. This resulted in increased anxiety for the client. I worked with staff at his day placement to develop a written schedule of his day, which featured a sequence of sensory strategies to be done every ninety minutes which I knew would enable him to calm himself throughout the day. The sensory strategies included use of the outdoor swing, deep pressure activities and use of a relaxation room. This facilitated him to complete his daily routine in a structured manner.
  • Sensory Integration Therapy: Sensory Integration Therapy programs can reduce challenging behaviour and self-stimulatory behaviour, improve interaction with the environment, and improve a person’s attention and performance in daily activities. I work regularly with people with Autism Spectrum Disorder (ASD) who have sensory processing difficulties. I added sensory strategies to the daily routine of a man with Autism, to enable him to focus and maintain his concentration on a computer-based program for 20 minutes, whereas at the start of our work together he was only able to concentrate for 5 minutes at a time.   
  • Supporting service users to make positive choices: Using a user-friendly interest checklist, a man with communication difficulty identified dancing as an area of interest to him. I then assisted the client in linking up with a dancing class in the local community.

Conclusion

People with a mental health illness and an intellectual disability face huge challenges in life. My experience working on an MHID team has allowed me to witness how my clients are impacted by these constraints. I have helped many of our clients overcome these barriers and succeed in life. The MHID Occupational Therapist helps the clients choose, participate and be successful in life and I believe it is imperative and essential to a person’s road to recovery. Occupational Therapists proactively use their skills to provide a platform and a voice for these people using the interventions described in this article. To better understand the role of the MHID Occupational Therapist I have outlined the types of interventions we can provide to enable this personal journey to recovery.

Cathal Keaney, MHID Occupational Therapist.

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