Question
I work at an adult day care for mentally ill and mentally disabled individuals. We have a wide range of clients, from very high functioning to extremely low functioning. The majority of the clients (102) keep busy with things like coloring, puzzles, making jewelry, movies, wii games, jobs... However there some that just don't want to do any of those things, or can't. It's hard when you try to get them interested in something and they refuse.. Then to watch them sit there, staring out the window makes me feel like I am failing them. For some reason my mind is blank when it comes to thinking of other options for these individuals to engage in. Any help would be GREATLY appreciated :)

Answer
Hello Lisa,

I've taken a little while to respond to you, as I am in the habit of always reading any questions I receive several times before I reply. I tend to find that this helps me focus - I always want to try to offer the best possible advice, and answer to the very best of my ability. So, here goes...

I have worked in the past as a Social Worker in Mental Health Services, and am currently doing further study in Psychology. As may be evident from this, I have a huge interest in how the mind functions, and in how this affects individuals and their behavior.

What I have often found - sadly - whilst working with people who are mentally disabled, or who experience mental illness, is that they are somehow seen as "less". Society seems to forget that they are not only people, but individuals. That each is different - with their own likes and dislikes, hobbies, interests, favorite foods, clothes, colors, and so forth. Whilst care of such individuals is intended as well-meaning, it can sometimes fall short; because of financial or resource shortages. Because of shortages of staff, or time. Sometimes, a client's individuality is lost.

I empathize with your position. Evidently, you are a person who wants to do the best for the people you work with. You wish to ensure that they are content, and feel involved in what is going on around them. Clearly, this must be difficult, as you state that you work in an adult day care centre for mentally ill and disabled individuals. It interests me that you use the word "individuals", as this points to the fact that this is how you wish to view them. That is a VERY good place to start from. YOU see these people as valid and meaningful human beings... that is why you appear to have such strong feelings regarding your desire not to fail them.

DO NOT MAKE YOURSELF FEEL GUILTY. It is a GOOD member of staff, not a BAD one, who asks questions - who feels that they could always do more. This shows that you are thinking about the needs of the people attending your day care centre. You are asking yourself what is expected of you - what you can do for them, and do with them. Social Workers talk of something called "reflective practice". This is where a member of staff looks back over work they have done - reviews it, and evaluates it, seeing this as an opportunity for learning. We all learn from what has gone before, and it is no bad thing for you to be naturally inclined to behave in this manner, and to question what you are doing. Without questioning, we cannot open the door to learning. Simply put... NO QUESTIONS = NO ANSWERS.

It is difficult to work with a range of differing functional abilities. Evidently, the functional ability of a client appears to impact upon their ability to participate in certain activities. However, other factors, too, may play a role. THIS is why it is always very useful to familiarize oneself with client notes, and to know what is in a client's file.

Understanding a client's background may give you some insight into why they behave a particular way. Some may, quite simply, be attending day care under duress. This is NOT your fault - but it may well be that they would rather be somewhere else. I have met many clients in my past who DID NOT want to attend day care, or DID NOT want to meet with their Social Worker, or whatever. Sadly, they had little choice. It was a necessary part of their care. However, such clients made it clear that they were NOT happy - they would refuse to join in, or they would refuse to acknowledge or engage with me. They might be silent, and look miserable; or they might be snappy and abrupt. Even people who cannot verbally communicate, can make known in such ways that they are not happy with what is going on. As a worker, you must always remember, and learn to accept, that there will be some clients who do not wish to have anything to do with you, or the care they are supposed to receive. It may well turn out that day care is NOT the best type of care for such clients. If so, their needs should be re-evaluated, and a more suitable alternative found.

That aside, and on a much more positive note, other clients may be homesick, or feel abandoned by family members. They may stare out of the window, marking time, waiting for their friend or relative to collect them, and take them home again. There may be ways of engaging such clients - and these involve getting family and friends on board. Some clients enjoy reminiscence, or nostalgia. They may like to look at old family photos, to read old letters, to look at past Birthday or Anniversary cards. Sometimes, making collages of such things can interest them. Allowing them to talk about their past (and present family) can also be another way of engaging them. They may like to do a very simple form of "researching their family tree". Basically, it is drawing (with staff help) a "family tree" of the family members they know, and pasting a picture of that person by their name. This can be an activity in its own right, or you could also ask them to tell you interesting stories about different family members.

Here, I am inclined to repeat to you the importance of knowing client's histories, and what is in their notes. Sometimes, these can afford you an insight into what that person is like, outside the day care centre. It may help you to pinpoint their interests, and to tailor activities to suit.

I do have a couple of other suggestions, however, in terms of more general activities. One that I have tried myself in the past, and did find sometimes worked, was what I loosely call "Aerobics". Now, I'm NOT suggesting a full on "Zumba" class here! No, it is simply movement to music. Even clients who are not physically very mobile can still participate whilst seated. Arm raises, foot raises, clapping in time to music... Such activities can be done individually, or as a group. For the less able, there is the pleasure of music and rhythm. They can clap along, or do simple arm, foot, leg lifts. More able individuals could do a wider range of moves, or more intricate ones. I have actually come across clients who started out like this, and became genuinely interested in keeping fit, and regular exercise. Remember, even when we think about our own experiences of sport and exercise, we do not start out fully fit, and capable of doing everything. We have to be gradually introduced to something new. We have to learn a new sport, or game. And, even for the fully fit and able, we must remember that everyone has different ability levels and interests. For example, I LOVE horse-riding and Pilates... but I am hopeless at tennis, and nowhere near fit enough for mountain-biking!

If you haven't tried it already, gardening can be of interest. There is a lot of current research that focuses on the benefits of outdoor activity like gardening. Some clients can derive a lot of pleasure, and self-esteem, from planting their own plot... growing their own veg and flowers. Obviously, activities such as this should be risk-assessed... but, at the end of the day, that is all part of the care planning process, anyway. I've listed a couple of research papers on the benefits of outdoor activity below.

Sensual, touchy-feely things sometimes work, as well. Collect together a selection of interesting objects - paint brush, bath plug, bubble wrap, seashell, cuddly toy, bell, cotton wool, jam-jar with a marble in it. Draw simple pictures of these on a piece of paper, or glue photos of them to a piece of paper. Write their names beneath each picture. You may try things like asking a client to close their eyes, and touching/tickling the back of their hand with a paint brush. Then ask the client to choose which picture they thought it was. Ash the client to shut their eyes, then feel the seashell, or hold it to their ear. Again, ask them to open their eyes and choose which picture they thought the item was. And so forth... Guessing can be fun, but the game also allows clients with severe cognitive dysfunction to re-learn certain skills and to re-explore their senses, such as touch, hearing, etc... To add interest, you may note that a ringing bell sounds similar to a marble rattling in a jar. Can your clients tell the difference? (By the way, when playing the game, YOU should take turns at guessing objects, too. It shows you are on a level with the client - you are human).

Gentle hand massage can also be pleasant, and relaxing, for a client who wishes to do little else. If you are granted permission (always ask family and senior staff first) you may wish to use a hypoallergenic (non-allergic) massage oil or body lotion. If not, just the sensation alone can be pleasant. It shows you are keen to interact with the client, and spend time with them. Humans are social beings, and interaction is important. It can involve ANY, or ALL of the senses. IT IS IMPORTANT TO BE AWARE OF THIS.

Some day care centres I have attended as a Social Worker (and have referred clients to) hire professional therapists to come in once a week to do things like Indian Head Massage, or manicure/pedicure. I believe this to be very important. People with mental health problems ( as I stated above) are still human beings, with thoughts and feelings. They may still like to look nice, and feel good. So why NOT have "pampering sessions"? Even if the centre where you work cannot afford, or does not wish, to hire a professional staff like you can still make a difference. Braiding or French-plaiting a female client's hair, simple hand massage... things like this can raise self-esteem.

How about going "back to basics" and thinking about YOUR OWN basic needs, wants, etc. This is a good starting point. You may find that humans all have basic impulses, needs, etc. These include a desire for company, to feel cared-for. To feel good about ourselves. To look presentable... things like this. The things that you would find it hard to cope without may be the things others would also find it hard to cope without. Activities at the day centre may need to include elements that meet these basic needs - things that enable clients to feel good about themselves.

If you find you are still struggling, then it is; as I noted above; time to ask serious questions about what is going on with a particular client. Are they homesick? Do they truly hate being here? Are they forced to attend? Are they traumatized by being amongst a large group of people? Are there other things going on that prevent them from participating fully... such as are they depressed? Or hard of hearing?

Remember... Care Planning is all about getting to know clients, and tailoring care to their needs. That is why Care Plans, and client notes, should be regularly updated. You are always gathering new information - it is part and parcel of your job. Information is key... what you learn about a client may enable you to find an activity that they enjoy.

Something to work on, here... I wish you all the very best.

And, if you are still at a loss, please do feel free to contact me again.

Regards,
Elaine Ellis.

P.S. Some useful reading/research materials...

1. "Physical Activity In Patients Who Are Severely Mentally Ill" - you will find this on-line at www.ncbi.nlm.nih.gov/pubmed/17010823

2. "Age Appropriate Activities For Adults With Profound Mental Retardation" - a book available via books.google.co.uk/books?isbn=1891278320 (you can view on-line, or purchase).

3. You could also look up "Thrive" which is a national charity that aims to help improve the lives of mentally ill and disabled people via involvement in horticultural activities. Their website is found at www.thrive.org.uk

4. And, finally, another article on the benefits of gardening and horticulture can be found on-line at www.kstatecollegian.com/2013/04/11/horticulture-therapy-program-offers-health-benefits-to-disabled/

Good luck!