By Anthony Yuill - specialist rehabilitation Occupational Therapist
As health professionals our role is to assess and treat people holistically. Yet, there is still the debate in healthcare as to what to treat first: physical disability or mental health? As Occupational Therapists we recognise that any assessment is not only the physical presentation that we see but one that also encompasses the mental and emotional health and wellbeing of our clients. With the holistic approach at the forefront of many health professions, the question should be 'Why not simultaneously treat them both?'
In 2016, the Mental Health Foundation published a document that stated more than 15 million people (30% of the UK population) have long term physical disabilities with more than 4 million of these people also developing mental health problems. There is numerous research and publications, inclusive of the Mental Health Foundation document (2016) that suggest those with physical health problems are at an increased risk of also developing mental health problems. Thus suggesting a direct link between physical disability and mental health. However, it is helpful to explore this link and understand why physical disability and mental health go hand-in-hand.
The impact on Mental Health
Whether a physical disability has a gradual onset or is a result of acute and catastrophic injury, an individual is likely to experience life altering physical changes. These physical changes will undoubtedly impact on their lifestyle, roles and relationships and indeed their entire lives. This impact can be profound and often traumatic. So much so, the World Health Organisation (WHO) developed guidelines in 2013 for addressing the mental health consequences of trauma and loss. These guidelines were compiled to assist primary care providers to offer immediate psychological support for individuals following a traumatic event.
Traumatic events can be defined as experiences that put either a person or someone close to them at risk of serious harm or death. They are more commonly experienced following road traffic accidents, worksite accidents, after violence or prolonged abuse and even following the onset of serious illnesses.
It is natural for the body to create a stress-like response following trauma. This can make people feel a variety of physical symptoms, for example raised blood pressure, increased heart rate/sweating and reduced stomach activity (loss of appetite). It can also make individuals behave differently and have more intense emotions, for example being 'on-edge', increased anger/frustration, reduced tolerance levels and altered mood. This response is often referred to as the 'fight or flight' response. This is natural in some situations. However, if these feelings persist - as often the case with physical trauma - they can lead to more serious mental health problems, including post traumatic stress disorder (PTSD), depression and anxiety.
The impact on Mental Health and the Rehabilitation Journey
Pain is subjective and is difficult to define. However, following traumatic injuries most individuals will develop the onset of chronic pain to varying degrees. Unlike acute pain, chronic pain continues beyond the expected healing time of the injury and is often difficult to treat. Chronic pain affects all aspects of a individual's life, including their relationship with others, their employment roles and their ability to participate in their normal activities. Often people with chronic pain will develop negative emotions and have increased feelings of guilt and shame (Turner et al, 2015). This could then lead to the development of depression and/or anxiety.
As healthcare professionals we need to look at the psychological and cognitive impact of pain within the rehabilitation journey. If we fail to do this, how can we say that rehabilitation has been holistic, client-centred and fully effective?
It is common that individuals may perceive their pain to be at a level in which they truly believe they can't perform certain activities. Albeit the physical response to pain may not be to such a degree, the level of perceived pain will undoubtedly affect an individual's sleep pattern. This can lead to greater isolation and feelings of depression. It is likely that these individuals would display avoidance behaviours. Thus impeding their rehabilitation (Moyle 2016).
Through exploring the psychological and cognitive impact we can implement treatments, such as cognitive behavioural therapy, to change individual thought patterns and, in turn, their behaviours. Thus prompting rehabilitation, through the reduction of avoidance patterns.
Prevalence, Challenges and the Rehabilitation Plan
Individuals who sustain physical injuries can experience a range of mental health problems related to their injury and changes in physical health and function. We have explored the links between traumatic events and the onset of conditions such as post traumatic stress disorder, depression and anxiety - the most prevalent following injury.
However, the individual may also experience changes to their behaviours - in that they may have reduced tolerance levels, increased frustration, irritability and also some may experience increased anger or be emotionally labile. The individual may also experience changes to their sleeping patterns. These conditions and changes can be further complicated and exacerbated when injuries result in an individual being unable to participate in everyday activities, such as personal care, work and/or socialising with peers. This should be considered within the rehabilitation plan.
Common symptoms individuals may experience following the onset of physical disability and mental health problems include the re-experiencing of the event in nightmares or flashbacks, avoiding activities and/or developing avoidance behaviours. In addition, people may also experience poor concentration, sleep disturbance, panic attacks and develop feelings of intense emotions, hopelessness and helplessness.
Through the onset of physical injuries - whether as a result of acute or gradual onset - the individual will undoubtedly experience a loss or significant change to their roles and relationships. Prior to their physical disability, many individual's will have roles such as partner, spouse, employee and/or driver. Following the onset of their physical disability, these individuals may have developed into the role of patient - dependant and requiring care or assistance to complete their basic activities of daily living. The changes to roles will undoubtedly lead to a change in their relationships. The individual may now class their partner/spouse as their carer, with the potential for a change in the relationship dynamic. The loss or change in roles and relationships play a key component within an individual's recovery and rehabilitation.
A loss of role or change in relationship can lead to greater feelings of helplessness, hopelessness and feelings of guilt and being a burden.
Alongside the physical pain and trauma of injuries, this has the potential to develop progressive negative feelings, leading to the onset of common mental health conditions associated with trauma. The development of these conditions will impede an individual's recovery and rehabilitation.
As every person is unique, so are their coping mechanisms. Although one person may be mentally capable of managing changes to their physical health and/or function, another person may not. There is no predictable sequence or pattern when exploring the psychological impact of injuries. However, a study by Taneal et al (2015) found that early identification of depression, anxiety and stress following injury - and subsequent preventative intervention - may reduced the long-term symptoms and negative impacts.
Due to the impact and common link, it is not surprising that the mental health implications associated with physical injury and disability are important areas that need to be considered when developing any rehabilitation plan. Through the development of a holistic plan, encompassing all areas and difficulties an individual may experience, the outcome for that individual will be maximised.
Further to this, the same study by Taneal et al (2015) noted that, in the three months following injury, 40% of their participants developed symptoms of depression, 34% developed symptoms of anxiety and 37% developed symptoms of stress. From this, is it clear that any rehabilitation plan needs to be reviewed and altered as necessary, in response to the individual needs of our clients.
As occupational therapists, we aim to improve health and well being through enabling participation in occupation. The link between physical injury/disability and the onset of mental health problems is clear. As a profession we can recognise that, not only does engagement in meaningful occupation promote good mental health, it can also assist recovery and help individuals to achieve their personalised outcomes. From full exploration of the individual within a holistic approach, we can investigate the impact of their physical disability in all areas, including the impact on their mental health. This will enable the development of holistic rehabilitation plans, that address all difficulties that an individual may experience. Through this holistic approach, the outcome of personalised goals will be maximised.
Moyal Sally, (2016) The emotional and psychological impacts of chronic pain (online article): www.ausmed.com/articles/chronic-pain-emotional-psychological-impacts
Mental Health Foundation (2016) Fundamental Facts about Mental Health (online document). Available from: www.mentalhealth.org.uk/file/2518
Taneal A, et al (2015) Incidence of depression, anxiety and stress following traumatic injury: A longitudinal study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Available from: https://sjtrem.biomedcentral.com/articles/10.1186/s13049-015-0109-z
Turner-Cobb, J. M., Michalaki, M. and Osborn, M. (2015). Self-conscious emotions in patients suffering from chronic musculoskeletal pain: A brief report. Psychology & Health, 30, 495-501.
World Health Organisation (2013) Protocols for Mental Health Care following Trauma (online document). Available from: www.who.int/mediacentre/news/releases/2013/trauma_mental_health_20130806/en/
Lloyd, C (2010) Vocational Rehabilitation and Mental Health, Wiley Blackwell
Creek, J (2014) Occupational Therapy and Mental Health, Churchill Livingstone
Duncan, E (2011) Foundations for Practice in Occupational Therapy, Churchill Livingstone
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