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Editor's Note: ADVANCE is pleased to introduce to readers Reji Mathew, PhD. An experienced mental health clinician and educator, Dr. Mathew will share both theoretical and practical perspectives on addressing the psychosocial needs of rehabilitation patients. Learn more about Dr. Mathew in her guest editorial on page 5. Look for her articles regularly in the last issue of the month.
Mental health is an often-neglected dimension of medical care. Yet health care practitioners are constantly contending with patients' emotional or psychological distress in clinical situations. During a medical crisis, patients shore up their emotional strengths, but most often we are seeing patients at their most vulnerable. Recognizing and responding to mental health concerns can ease added stress for patients and assist practitioners in carrying out treatment interventions with more success.
This article will review basic mental health principles and referral recommendations. The function of this article is to orient readers to mental health concerns; future articles within this year-long series will review techniques and strategies.
Understanding Mental Health
On a basic level, mental health is a state of wellbeing. On a deeper level, mental health is a therapeutic domain encompassing several dimensions that all work together: capacity to tolerate stress, coping, capacity for problem solving, identifying and expressing emotions, and making use of social support.
Unfortunately, in our culture there is a lot of shame in seeking mental health treatment. Many individuals split their views of care for the mind and care for the body. For example, most patients have no hesitation seeking medical intervention for a broken ankle, but the same does not apply to broken feelings that don't heal.
The reality is that no person is immune from emotional imbalance in times of stress. Even the most resilient person can be vulnerable to mental health concerns, as each person cannot predict how his or her mind and body will absorb trauma until it happens. When emotional stresses arise in treatment sessions, OT professionals can be pivotal in educating clients about mental health treatment.
Getting Started
To begin, it is important to establish a baseline during the initial evaluation. How does the patient "look, sound and feel" in your therapeutic interactions? Self care, mood, speech and interpersonal interactions often have a lot to do with internal mental health states. Illness and disability at any age, regardless of acute or chronic status, challenge patients on a variety of emotional levels: fear of dependency, loss of control, accepting new limitations and undue stress on coping capacities.
If the patient is entering treatment with a pre-existing mental health condition such as depression or anxiety, it is important to distinguish if the current emotional stress is acute or chronic. This information can help with treatment planning, as some patients may need more support than others. Establishing a baseline is an important marker for assessing a clients' functioning throughout the course of treatment.
In terms of determining the need for mental health interventions, basic assessment questions are a helpful start:
How are you coping?
Do you have someone to talk to?
Who are your supports?
It is important to ask these questions at each phase of treatment-for example, at the beginning of treatment, when introducing a new skill, or during discharge planning, so that patients can plan for ongoing support.
Next, be on the lookout for reactions. Health care professionals need to listen not only for the emotional impact of medical treatments, but also for the subsequent psychological reactions patients may be struggling with. Common reactions include a low mood, anxiety or low motivation. While these reactions are human, what we are looking for are reactions that have a pervasive intensity, duration or frequency. In other words, look for reactions that interrupt a patient's ability to make good use of a session, implement exercises or meaningfully participate in his or her care.
Mind-body Connection
Recovery and rehabilitation require physical energy, but more importantly, they require emotional and mental energy. There are a few central points to consider when assessing how patients can make the best use of their treatment. Do they have the proper psycho-education about their disease? Do they have adequate problem solving skills to speak up about their needs when an intervention needs to be modified or adapted?
I never cease to be amazed when I come across patients who have been handed a diagnosis, particularly a chronic one, and have never been given the proper education on how to plan, cope or accept their condition. Most chronic conditions, such as multiple sclerosis for example, require multiple skills to achieve wellness: stress management, managing relapse cycles and lifestyle modification.
It is also critical for occupational therapists to foster a mind-body connection. When patients are feeling overwhelmed by their symptoms, a common coping strategy of the psyche is to merge the mind and the body. One patient with chronic fatigue syndrome skillfully articulated this process experience to me:
"When I would feel physically fatigued, I would then collapse into feeling emotionally fatigued and then that would lead to feeling depressed. It was a vicious cycle. I could not get out of it. Once my counselor taught me how to distinguish my physical sensations from my feelings, I was then able to apply lifestyle modification techniques to work with my physical fatigue instead of drowning in my symptoms."
Teaching patients basic mind-body concepts can assist them in maintaining emotional resilience and commitment to caring for the body over the lifespan. It is important to emphasize to patients that this skill is an ongoing learning curve and can aid in designing a comprehensive treatment.
Mental Health Interventions
Mental health interventions include individual treatment, family work, group therapy, coping-skill therapies and psychopharmacology interventions. There are a variety of treatment approaches, but generally they fall into two main categories: supportive therapies (talking out concerns to gain perspective), or skills-training therapies (to improve coping skills). With medical concerns, most patients require a combination of both modalities.
To introduce mental health interventions in OT sessions, there are a few steps practitioners can take.
First, it is helpful to provide psycho-educational material to patients informing them of the difference between lay persons and mental health professionals, i.e., that mental health professionals are trained listeners who know how to give specific feedback to patient about effective coping and how to work through psychological symptoms. It is also important to have reading material available to inform patients on ways to recognize symptoms and when to see a professional.
Second, there are numerous internet resources available. Many disorders have specific websites, such as the Depression and Bipolar Support Alliance. This Web site, for example, has a section titled "Stories of Depression." Connecting patients to such narratives can assist them in learning how others have worked through similar problems and also normalize help-seeking. In addition, online communities can provide support to caregivers.
Next, it is critical to have direct relationships with mental health clinicians, so you can problem solve on an ongoing basis about clients who may need mental health intervention, and refer as needed. I would recommend being connected to both local and national support networks. Whatever the point of entry, especially if the patient is therapy-phobic, a variety of venues can provide the beginnings of a therapeutic experience.
The practitioner-patient relationship is the foundation of a therapeutic alliance and successful treatment. Every health care practitioner, no matter his or her specialization, participates along a continuum in planting the seeds of overall wellness and mental health.
Dr. Reji Mathew is a psychotherapist/clinical instructor at the New York University Student Health Center. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at rqm3463@nyu.edu.
Useful Online Resources
For Symptom-Specific Support
The following Web sites offer excellent handouts, educational material and self tests for various symptom areas such as depression, anxiety and post-traumatic stress.
National Institute for Mental Health: www.nimh.nih.gov
Depression and Bipolar Support Alliance: www.dbsalliance.org
Anxiety Disorders Association of America: www.adaa.org
To Locate a Mental Health Provider
The following Web sites have links to "find a practitioner" services in your area. Clinical social workers, psychologists and psychiatrist are all licensed mental health providers. Psychiatrists are licensed to provide psychopharmacological intervention.
American Psychological Association: www.apa.org
National Association of Social Workers: www.naswdc.org
American Psychiatric Association: www.psych.org
For Additional Reading
This narrative is the compelling story of Matthew Sanford, who became paraplegic at age 13. His memoir describes his journey of how he re-established a mind body connection. His organization, Mind-Body Solutions, promotes mind-body work and yoga for disabilities.
Waking: A Memoir of Trauma and Transcendence, by Matthew Sanford
Mind Body Solutions: www.mindbodysolutions.org
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