Multidisciplinary approach to mental health issues, how a physiotherapist fits into the team

Original Editor - Vidya Acharya

Top Contributors - Vidya Acharya and Amrita Patro  


Introduction:

One of the statutory functions of the Mental Health Commission is to foster and promote high standards of care and best practice in the delivery of mental health services. Planning for the Future (Department of Health, 1984) recommended the establishment of multidisciplinary teams as “different approaches to treatment and the participation of people from a number of professional disciplines are required to cater adequately for the needs of the mentally ill”. It recommended that the psychiatrists and psychiatric nurses, psychologists, social workers and occupational therapists should form “psychiatric teams” to provide comprehensive treatment and care for the mentally ill.

A key strength of multidisciplinary teams is that the combined expertise of a range of mental health professionals is used to deliver seamless, comprehensive care to the individual. The research evidence supports a multidisciplinary team working as the most effective means of delivering a comprehensive mental health service to people with mental health problems, especially those with long-term mental health problems (Tyrer, 1998)[1].

The rationale for multidisciplinary team working:

The delivery of mental health treatment and care by multidisciplinary teams has developed in parallel with the demise of large psychiatric institutions (Leff et al., 2000). Since the 1950’s mental health care has moved from the mental hospital to community-based care. This movement was the result of improvements in pharmacological treatments along with key social, political and economic trends. These included increasing emphasis on human rights, understanding of the detrimental effects of institutionalisation, the involvement of family and service user organisations, value for money, and the influence of the therapeutic community movement. The growth of community-based care has been largely pragmatic, reflecting a clinical view that ‘the needs of the severely mentally ill can rarely be met by a single individual’ (Burns & Lloyd 2004; Onyett, 1992)[1].

The need to establish community-based alternatives to hospital treatment and to ensure the coordinated health and social care for the severely mentally ill established the team as a central feature of virtually all forms of modern mental health care[1]. According to one of the four guiding principles of the Health Strategy Quality and Fairness: A Health System for You (2001) – person-centeredness, describes very well the central aim of providing mental health care through a multidisciplinary team. A person-centred health system is described as one which “identifies and responds to the needs of the individual, is planned and delivered in a coordinated way, and helps individuals to participate in decision making to improve their health”. Mental health services have been to the fore in providing this type of person-centred care for some time. The starting point is the individual using a mental health service. Individuals with mental health problems often have a wide range of needs that may be social and psychological. They wish to have access not just to doctors and nurses, but to psychologists, social workers, occupational therapists and other therapists. They want access to the range of interventions offered by this variety of mental health professionals[1].

What is multidisciplinary teamwork?

The multidisciplinary team is members of different professionals working together. A team is described as a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. There are different definitions and descriptions which capture important features of multidisciplinary work. According to Jefferies & Chan (2004), multidisciplinary team working is described as the main mechanism to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care. According to Junor, Hole & Gillis ( 1994 ), multidisciplinary team working is known to “maximise clinical effectiveness”.

The teamwork just doesn't happen magically. The teams need to:

  • have shared goals and values,
  • understand and respect the competencies of other team members,
  • learn from other disciplines and respect their different views and perspectives.

Individual team members may need to reassess exclusive claims to specialist knowledge and authority in order to form effective multidisciplinary teams which can provide the best possible care to the individual service user[1].

Why are multidisciplinary teams important?

Multidisciplinary teams convey many benefits to both service users and the mental health professionals working on the team, such as continuity of care, the ability to take a comprehensive, holistic view of the service user’s needs, the availability of a range of skills, and mutual support and education.

With increasing specialization in healthcare, and expanding knowledge about health and mental health conditions, having a forum for assembling groups that reflect different areas of specialization is increasingly necessary. Some of the benefits of multidisciplinary team models include improved consumer health outcomes and functioning, enhanced quality of life, reduced costs, and utilization of medical services [2] 

Members of the multidisciplinary team:

The mental health team is made up of a group of people each of whom possesses particular skills and expertise. The team consists of a consultant psychiatrist, his registrar and housemen, nurses, clinical psychologists, social workers, occupational therapists, speech therapists, physiotherapists, dietician and hospital chaplain. Some members of the team may meet daily or weekly to discuss patient treatment and progress. Other members will provide their services as and when necessary[3]

Each member of the multi-disciplinary team needs to have an understanding of other members' roles in meeting the needs of patients. There is usually some blurring of roles in the therapeutic milieu and team members will not relate equally to every patient. Some team members may act as key workers with particular patients or groups of patients. The person who acts as the key worker for a particular patient may be selected from any member of the team, and therefore from a number of different disciplines. This person may be the nurse, the social worker, the psychologist or another professional with appropriate training.

How a physiotherapist fits in the team?

Most health professionals, commissioners, policy-makers and the general public recognise physiotherapists as experts in back and neck pain, but would not be aware of the contribution they make to the care of the people with mental health problems[4]. The importance of the implementation of physiotherapy in both common and severe mental health disorders and psychiatry is underestimated. As healthcare providers, physiotherapists are also involved in the prevention and promotion of health, including mental health. It is their responsibility to inform individuals adequately about mental health, eliminate misconceptions about mental illness and refer them when necessary to specialized professionals in mental health and psychiatry[5]. In clinical practice, physiotherapists are confronted with individuals with frail mental health, chronic musculoskeletal disorders, chronic pain and psychosomatic disorders. Components of mental health are interwoven in their patient's stories and they deserve an appropriate physiotherapy intervention. More severe physical diseases such as cardiovascular diseases, Parkinson's disease, rheumatoid arthritis, hypertension, diabetes mellitus, metabolic syndrome, asthma, asthma/chronic obstructive pulmonary disorder (COPD), cerebrovascular diseases (stroke), obesity, epilepsy, cancer and other diseases are frequently accompanied with a ‘rollercoaster’ of emotions, feelings of anxiety and pain[5]. Basically, individuals with mental disorders have numerous physical health complaints (cardiovascular diseases, metabolic syndrome, obesity, osteoporosis, etc.) due to medication, sedentary behaviour or inactivity and consult primary health services.

Physiotherapists are highly trained and experienced in managing physiological conditions such as musculoskeletal conditions, cardiorespiratory and neurological conditions.[6] Through a multidisciplinary approach, physiotherapists can address the physical well-being of people with mental health conditions from across the lifespan. Improvements to physical well-being can improve mental well-being and prevent the development of mental health conditions, such as depression which is often associated with other physiological conditions. With an established role in assessing and diagnosing musculoskeletal and physical conditions, physiotherapists can be engaged in planning, decision making, advocating for, and case management of the physical health of people with mental health conditions.

There is evidence that improvements in body function including balance, posture and flexibility are linked to a sense of improved security and better self-esteem. Improvements to posture, for example, can benefit self-image and raise mood, in addition to decreasing back or neck pain. As well as preventing its onset, strong evidence also exists to suggest that an appropriate exercise regime effectively improves the well-being of people with depression[6]. Physiotherapists can also encourage people with mental health conditions to take an active role in their own care by supporting and providing resources to facilitate self-management. It is acknowledged that enhancing physical health will promote mental well-being.

In summary, it all adds up for the health care providers to optimize access to physiotherapy for people with mental illness, give them the most appropriate treatment and give additional thought to the mental health dimension of their patients’ physical conditions.

Physiotherapy interventions in mental health.

Physiotherapists working in the mental health sector were amongst the first to apply holistic and biopsychosocial approaches[5] to physiotherapy assessment and interventions – these approaches are now recognised within the physiotherapy profession and utilised in other areas including complex pain management.

  1. Basic body awareness methodology - It is a 'person‐centered' physiotherapeutic movement awareness training programme that is directed towards daily life movement and is used in multiple clinical settings, including primary health care, pain rehabilitation and psychiatric physical therapy, as well as in health promotion. It is founded upon a three‐dimensional approach to human movement: learning about and through movement and learning while being in movement. Body awareness combines a series of exercises that are related to posture, coordination, free breathing and awareness. It offers training situations that focus on healthy movement aspects, lying, sitting, walking, running, using the voice, relational movements and massage.
  2. Psychomotor therapy with children and adolescents - offered in different disciplines, including mental health care, child psychiatry, youth care, special education and rehabilitation, as well as private practice. The cornerstones of this approach are body awareness, movement and physical activities
  3. Norwegian psychomotor physiotherapy - Indications for this physiotherapy approach are the conditions associated with strain and functional disturbances in the musculoskeletal system as well as psychosomatic disorders. This approach focuses on how the past continues to influence the present, the psychoanalytic approach develops the client's awareness of what can be done to correct the harmful effects of the past. Symptoms are viewed as an expression of a disturbance in posture, respiration, muscle tension or autonomic functions, which are often related to emotional conflicts or mental problems. The patient's body and self‐awareness are taken into consideration. Norwegian psychomotor physiotherapy aims to release respiration through an interaction among breathing, the musculoskeletal system and emotions and to develop flexibility, versatility and the stability of the person.
  4. Relaxation therapy and mind‐body‐related approaches - This valued therapeutic approach is frequently used in mental health care, and physiotherapists in mental health care apply relaxation training as one of their interventions. Relaxation is used as prevention (to protect the body), as a treatment (for instance, to relieve stress in individuals with hypertension, tension headache, insomnia and panic) or as a coping skill (to relax the mind and to promote clear and effective thinking). Yoga, Tai Chi, mindfulness‐related exercises and Pilates are also used to cope with stressful situations.
  5. Psychomotor physiotherapy for severe mental health problems - This approach aims to realize clearly formulated consent goals, which are relevant to the patient's mental health problems (depression, anxiety, schizophrenia, autism, eating disorder, etc.). This approach is based on evidence‐based research and 50 years of clinical practice.
  6. Psychosomatic physiotherapy approach - The psychosomatic‐oriented physiotherapist is inspired by cognitive behavioural interventions including graded activity and active pacing therapy. The therapist uses a number of specific awareness‐raising methods such as relaxation techniques, breathing and communication methods, (bio‐) feedback, problem-solving strategies and stress management.
  7. Exercise and physical activity in mental health - The health benefits of regular exercise are improved cardiovascular fitness, improved sleep, better endurance, a positive influence on metabolic syndrome and diabetes, stress relief, improved mood, increased energy and reduced tiredness. Exercise reduces anxiety, depression, negative mood and social isolation and improves self‐esteem, cognitive functions and quality of life.


[7]

The International Organization of Physical Therapy in Mental Health (IOPTMH)

Is a subgroup of WCPT, was developed in 2011 from an international network of physical therapists working in the field of psychiatry and mental health. It developed a definition that generally describes the field of physiotherapy in mental health that is recognizable among most colleagues across the world.

Physiotherapy in mental health is a speciality within physiotherapy, implemented in different health and mental health settings: psychiatry and psychosomatic medicine. It is Person‐centered and provided for children, adolescents, adults and older people with common (mild, moderate) and severe, acute and chronic mental health problems, in primary and community care, inpatients and outpatients. It provides health promotion, preventive health care, treatment and rehabilitation for individuals, groups and in‐group therapeutic settings. They create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment by applying a model including biological and psychosocial aspects. It aims to optimize well‐ being and empower the individual by promoting functional movement, movement awareness, physical activity and exercises, bringing together physical and mental aspects. It is based on the available scientific and best clinical evidence. Physiotherapists in mental health contribute to the multidisciplinary team and inter‐professional care[5] 

Conclusion:

Within mental health care systems, physiotherapists should be seen as valuable members of a multidisciplinary approach. Several strategies[8] should be used to initiate and stimulate physiotherapy within the mental health care systems:-

  1. Continued medical education should be used to inform supervising mental health care professionals on the importance of physiotherapy.

2. Policymakers should be made aware that investment in physiotherapy could optimize mental and physical health improvements while the inclusion of physiotherapists in lifestyle interventions will improve adherence and reduce dropout and consequently will be cost-effective.

3. Physiotherapy institutions should focus on the importance of physiotherapy for mental health in order to improve the competencies of their graduates in this field.

References:

  1. 1.0 1.1 1.2 1.3 1.4 Multidisciplinary Team Working: From Theory to Practice; Discussion Paper; Mental Health Commission January 2006
  2. Kutash K, Acri M, Pollock M, Armusewicz K, Olin SC, Hoagwood KE. Quality indicators for multidisciplinary team functioning in community-based children’s mental health services. Administration and Policy in Mental Health and Mental Health Services Research. 2014 Jan 1;41(1):55-68.
  3. Martin P. (1987) The multi-disciplinary team in mental health.The multi-disciplinary team in mental health In: Martin P. (eds) Psychiatric Nursing. Palgrave, London
  4. Pope C. (2009). Recovering mind and body: a framework for the role of physiotherapy in mental health and well-being. J Publ Ment Health, 8, 36–9.
  5. 5.0 5.1 5.2 5.3 Michel Probst, Physiotherapy and Mental Health, Chapter 9, Clinical Physical Therapy
  6. 6.0 6.1 Australian Physiotherapy Association Position Statement; Mental Health and Physiotherapy; December 2011
  7. UNSWTV Exercise therapy for mental illness Available from https://www.youtube.com/watch?v=_6JIXnwW03Q
  8. Vancampfort D, Stubbs B, Probst M, Mugisha J. Physiotherapy for people with mental health problems in Sub-Saharan African countries: a systematic review. Archives of physiotherapy. 2018 Dec;8(1):2.