PROFESSIONAL ROLES AND MULTI-DISCIPLINARY WORKING
MEERA ROY, JANET
BAILEY, LOUISE ELLIOT, LIZ KELLY, CARLENE MCKENZIE,
People with learning disabilities have a higher than average need for health care services. Over 60% of people of this group, who live in the community, have at least one chronic disorder, which is sufficient enough to warrant on-going medical intervention. People with a severe learning disability often have associated physical problems such as epilepsy, sensory impairment, cerebral palsy and difficulties in speech and communication. Various studies have shown that up to one third of children with severe learning disability suffer from epilepsy. Mental health problems are three to four times more common in this group than in the general population.
Most people with learning disabilities live in the community, either with their families or with paid carers. In order to do so, they need access to respite care to give their families a break, residential care in the event that their families are no longer able to look after them, daytime occupation and opportunities for education, leisure and employment. The emphasis on closure of long-stay learning disability hospitals has meant that people with learning disabilities live and receive care in the community. In view of the complex needs that people with learning disabilities have, the skills of a variety of professionals are needed. In most parts of the country these professionals work together as a team. One of the most important resources for a person with learning disability and their carers in the community is the Community Learning Disability Team.
COMMUNITY LEARNING DISABILITY TEAM
Community learning disability teams usually consist of community nurses for people with learning disabilities and specialist social workers as well as other professionals including psychiatrists, psychologists, occupational therapists, physiotherapists, behaviour specialists and speech and language therapists working closely to provide comprehensive assessments and management strategies for the people referred to the team. The philosophy of the teams is to support people with learning disabilities and their carers to enable them to have as ordinary and fulfilling a lifestyle as possible. As teams can be organised differently it is useful to have an understanding of the skills that different professionals in learning disability services have.
Community Nurse for People with Learning Disabilities
Community nurses have special training in learning disability and usually are registered nurses in mental handicap (RNMH). They work in partnership with individuals to improve their autonomy by mitigating the effects of disability and achieving optimum health. They facilitate and encourage involvement in local communities and maximise their clients’ choice. They enhance the contribution of others involved. They have a central role in health surveillance and health promotion. Some of the areas where a nurse may be involved include management of epilepsy, emotional problems, diet, continence, care of pressure sores, personal hygiene, and management of stress and promotion of personal safety. They may also carry out specialised therapies such as dealing with bereavement and relationship difficulties.
While the primary function of the community nurse has a clinical emphasis, they work closely with other members of the multidisciplinary team to reduce the consequences of any learning disability to a minimum.
Social Worker
The primary aim of the social worker is to support, advise and assist people with a learning disability and their families to live within the local community. They can help with regard to welfare benefits, housing, health and hygiene and counselling. One of the main pieces of legislation that the community teams work with is the Community Care Act 1993. This entitles a person to an assessment of needs, which could result in the individual identified as having a simple, straightforward or complex need. An example of a simple need would be to arrange respite care for a person with a learning disability. An example of a complex need would be to find a home for a person with a learning disability who had an additional mental illness and deafness. Teams are increasingly working with people with complex needs which require planning meetings, setting up of care packages with multi-agency and multi-disciplinary input e.g. involving psychiatrists, psychologists, voluntary and independent agencies The social worker is often the only individual (sometimes called Care Manager) with the responsibility to apply for funding and to monitor and review care packages.
Occupational
Therapist
The Occupational Therapists promote and restore health and well being in people of all ages using purposeful occupation as the process or the ultimate goal. In this context, occupation is the meaningful use of activities, occupations, skills and life roles, which enables people to function purposefully in their daily life (College of Occupational Therapists).
The Occupational Therapist adopts a holistic, client centred approach shaped by the principles of social role valorisation. This is useful in providing a framework within which individual needs can be assessed where appropriate and therapeutic programmes of intervention can be devised to maximise levels of function and independence. Assessments take place in a variety of settings e.g. the client’s home and day centres and involve both clients and families. The occupational therapist obtains relevant medical and social history, details of life events and current life roles. Criterion based assessment e.g. Star Profile, occupational therapy checklists and task analysis of activities are carried out. At the end of this process, a planned programme of intervention is devised.
Occupational therapists enable people with learning disabilities to maximise their physical, emotional, cognitive and functional potential by teaching or enhancing skills like eating, dressing, cooking and shopping. The skills necessary for the above can be improved by memory training and improving physical ability. The therapists help clients prepare for more independent living and manage anxiety. They adapt techniques to maintain independence e.g. using pictorial checklists for cleaning routines and shopping lists. Group work techniques encourage social interaction. Home environment can be manipulated to increase independence or enhance quality of life by the provision of specialised equipment like bath aids, eating utensils and adaptations to compensate for dysfunction e.g. improving accessibility for wheel chair users.
Occupational Therapists enable clients to have a meaningful life style by appropriate use of leisure, exploring opportunities for education and training and achieving a balance between personal, domestic, leisure and education/work related activities. They also provide practical advice to clients and carers to maintain independence where deterioration in ability is anticipated as in some one with a progressive neurological deficit. Interventions are regularly monitored to ensure that goals are being achieved. Occupational Therapists work closely with the other professionals in the multidisciplinary team to ensure that a comprehensive care package is delivered.
Clinical Psychology
Clinical psychology is the application of psychological theory and research when working with people to promote health and cure and prevent illness. Psychological approaches can be applied to a range of difficulties. These include relationship problems, sexual dysfunction, depression, anxiety, obsessive compulsive disorders, eating disorders, alcohol related problems and conduct disorders.
Psychological techniques have also been applied to a range of lifestyle issues such as stress inoculation, smoking cessation and weight reduction. There has recently been an increase in the use of psychological techniques in the treatment of people with physical health problems, for example, chronic pain, and rehabilitation after cerebrovascular accident and head injury.
A range of psychological models may be employed by applied psychologists who work in clinical or health settings. These models include the cognitive behavioural approach, the humanistic approach to therapy, psychodynamic approaches and behavioural approaches to treatment. This list is not exhaustive and the reader should refer to other texts for a complete description of each of them.
Clinical psychologists who work with people with learning disabilities use all of these models, including psychodynamic and cognitive behavioural approaches - previously viewed as only applicable to the more intellectually able people in society.
People with learning disabilities are no different from the rest of the population in terms of their susceptibility to suffering from physical or mental ill health. Indeed, there is evidence to suggest that they are more susceptible to physical and mental illnesses. The Clinical Psychologist working with them will, therefore, need to use their chosen therapy model to assist their client to overcome their difficulties.
The role of the Clinical Psychologist within the multi-disciplinary team is to offer expert clinical skills for clients with problems that are considered to be amenable to psychological intervention. In addition to direct client work, the psychologist can offer support and supervision to colleagues who have adopted a psychological approach to their work.
Behavioural Support Services
The last ten years have seen great changes in both the content and delivery of behavioural support to individuals with learning disabilities. Remington (1993) refers to a “sea change of emphasis” away from simply applying “modification techniques” which were often punitive towards non-punitive interventions based on an analysis of the problem situations.
Value changes (e.g. social role valorisation) have been influential in this, also the recognition that the “challenging environments” (McGill, Toogood, 1994) in which clients often live can combine with their disabilities to give them no alternative “non-challenging” ways of meeting important ordinary needs (Mansell, 1994).
The current behavioural “technology” is supported and informed by a wealth of innovative research. Assessment shows an emphasis on “functional analysis” and typically involves identifying the function or purpose of behaviours, the sufficient and necessary stimuli that elicit it and the full range of individual and environmental factors that maintain or mediate the situation. The behaviour may, for example serve a communicative function. Head banging maybe the first response to headache or toothache in an individual with poorly developed communication skills.
Interventions are behaviour decreasing programmes and can be a combination of increasing functional skills relevant to the problem, adaptations to individual’s environment, e.g. change in activities and an emphasis on lifestyle or quality of life changes as a means and an end. The practicalities of delivering such services which require intensity of support and skills have led to a rapid expansion in the number of specialist support teams e.g. Clwyd Intensive Support Team(Toogood, et al 1994,a).
Whilst very impressive evaluations are available on what such services can achieve (Toogood et al, 1994,b), it is fast being acknowledged that such teams are not sufficient in themselves. Indeed, Mansell (1994) has noted that raising the effectiveness of “mainstream” learning disability services to prevent and cope with challenging behaviour is vital if they are to avoid propagating more problems than the specialist services are able to cope with. Collaboration with other professionals also dealing with behaviour problems e.g. psychologists and psychiatrists is essential for improved outcomes for interventions made.
Speech and Language Therapist
The role of speech and language therapist with adults who have learning disabilities is concerned with assessment, intervention and training.
Assessment involves gaining information from informal observation and the use of formal assessments. The therapist obtains information about the client’s communication skills including their level of comprehension, means of expression, attention and listening skills, interaction and social skills. They are also involved with the assessment of associated behaviour problems, feeding and drinking skills. Assessment needs to be carried out over a period of time.
Intervention with this client group may be direct or indirect and clients may be seen either individually or part of a group. Direct intervention may, for example, be focusing on the teaching of new Makaton signs (a communication system based on British sign Language) whereas indirect intervention would focus on transferring this skill into the everyday environment. Generally a total communication approach is advocated. This is the use of signs, symbols, objects and pictures with speech in order to maximise the communication environment and thus the communication potential of the client. Intervention strategies are evaluated dependent upon the needs of the individual.
Training staff, carers, parents and all others involved is a major commitment of the speech and language therapist. Training may be carried out to look at general communication issues or to address and train in specific skill areas, for example, Makaton training. Training is seen as an essential part of the overall management of this client group and a way of encouraging success of communication within the every day environment. The role of the speech and language therapist is most effective when it is as a part of the multidisciplinary team.
Physiotherapy
The physiotherapist is an expert on assessment and analysis of movement and function who uses a range of skills, techniques and concepts in the management and treatment of physical condition. Treatment programmes are designed to promote the client’s personal competencies.
The physiotherapist will compile, when necessary, intervention programmes which are individually tailored for clients. Where possible, these programmes are incorporated into everyday activities to provide stimulation and motivation thus enabling clients to gain new skills and further independence. These programmes, when applied, are monitored and evaluated. The physiotherapist works as a member of a team. This team can be small or extensive in size if the client has multiple needs.
The programme of suitable intervention is based on what sometimes can be an extensive assessment. The purpose of the assessment is to identify strengths and weaknesses in the individual’s physical development. This may include variations of muscle tone, the absence or presence of movement and the extent of physical deformities, if any. Each individual case must be recognised for its own uniqueness.
The intervention programmes which are individually compiled may include the use of sensory input to facilitate or inhibit the central nervous system, the application of neuro-developmental concepts, the application of skilful manual techniques, some principles of conductive education, hydrotherapy, swimming, education and training of carers and staff in moving and handling techniques, support for carers in their unique role and alternatives to aggressive and challenging behaviour in the form of physical activities and exercise.
People with profound multiple handicaps are highly prone to physical deformities and increasing stiffness as they get older. The provision of several positions that are comfortable for such clients are essential as part of a daily care package. People with cerebral palsy often need intensive input from physiotherapists to maximise their functioning and reduce deterioration characterised by contractures and reduced strength and movement.
The physiotherapist maintains systematic records of client’s physical abilities. The importance of doing so is highlighted when any deterioration takes place. The type of deterioration and its rate is significant. There will be a degree of increased impairment as the years advance. However, this must be judged in the light of any physical handicap as well as the age of the client. Any activities chosen to encourage and promote movement must be judged against the suitability for the client and take into accounts a client’s choice and lifestyle.
The physiotherapist also has a key role in health promotion. As a direct result of this physiotherapy departments have taken the lead in the introduction of safe moving and handling techniques. These have proved invaluable in preventing carers developing back injuries when providing physical care for people with multiple disabilities.
Psychiatrist
A psychiatrist is a qualified medical practitioner who then receives further training in all branches of psychiatry over a four-year period. After successful completion, further training in the psychiatry of learning disability for at least three years leading to accreditation follows this by the Royal College of Psychiatrists.
The core roles of the Consultant Psychiatrist are to provide assessment and treatment for people with a learning disability who have mental illnesses, dementia, behaviour disorders, neuropsychiatric disorders including epilepsy and for those who come into contact with the courts or police because of their behaviour. This is done in a variety of settings depending on where the client is. Thus it can occur in schools, work settings, out patient clinics, hospitals, prisons and in people’s own homes.
Assessment usually leads to a diagnosis of one or more problems and a treatment plan that is arrived at after discussion with other members of the team. Common treatments used by psychiatrists include advice and medication in the management of mental illnesses such as schizophrenia and depression and other conditions such as epilepsy. Psychiatrist are regularly involved in the use of the Mental Health Act to treat some patients who need treatment but are unable to consent or refuse treatment on account of their mental disorder. Other treatments include psychotherapy and advice on behaviour problems They are also able to advise carers and professionals on issues such as consent to treatment, ability to parent, etc. The service is provided to people of all age groups. The Royal College of Psychiatrists recommends that there should be one Consultant Psychiatrist for every 100,000 population though in practice this is rarely the case.
Like other members of the team, a psychiatrist is most effective working closely with other professionals. Close joint working arrangements often exist for collaboration with psychologists and nurses with joint assessments and treatments being provided. When this happens with behaviour support teams it becomes possible to diagnose and treat a wide range of mental illnesses which can masquerade as behaviour disorder.
The involvement of the Psychiatrist is further discussed in other chapters.
In the preceding section an attempt has been made to outline the specific roles of the professionals in the community learning disability team. It is important to emphasise that these professionals also carry out their roles as members of a team in a variety of settings. Multidisciplinary working is the norm in most in patient settings. These could be short-term residential assessment and treatment units or specialised forensic medium secure services. Some of these are described more fully in Chapter 12.
How
Do Teams Work?
A following case example illustrates how teams often approach clinical problems.
Susan was a 31-year-old lady with a moderate learning disability who lived with her family. Her parents are both employed and during the day Susan attends a sheltered workshop. The manager of the workshop has referred Susan to the team. According to him Susan has become withdrawn and her level of work has deteriorated. Since her motivation appears to be poor she is at risk of losing her placement.
At a team meeting the referral is discussed and it is agreed that a community nurse would visit Susan at the day centre and assess the situation. This revealed that Susan had indeed started deteriorating for the last three months. She had Down’s syndrome and had showing a loss of interest in favourite activities such as cooking, going out shopping and meeting her friends. The nurse felt that in order to establish the reason for this change a comprehensive assessment was needed. A full hearing and vision test was carried out by the community audiology service and an experienced optician. A referral was made to the general practitioner to examine and investigate her for conditions such as anaemia and impaired thyroid functioning. As these tests were negative, a referral was made to the psychologist to measure cognitive functioning to rule out early dementia. When this did not reveal any abnormality, she was referred for a full psychiatric assessment. This revealed that Susan was indeed significantly depressed with loss of weight, appetite, lowered mood and occasional weeping spells. This was found to have started after her best friend had moved to another centre. This move had not been explained to Susan and she was under the impression that he had died. A short course of antidepressant medication along with resumption of regular contact with her friend lead to a gradual improvement and a return to her previous level of functioning.
This example demonstrates that multidisciplinary and multiagency working is the only way forward to ensure that people with learning disabilities receive appropriate services. No one professional can function independently and fit together like the pieces of a jigsaw puzzle.
REFERENCES
Mansell, J. (1994) "Challenging Behaviour: The Prospect for Change. A Keynote Review". British Journal of Learning Disabilities Vol. 22. Pages 2-5.
McGill, P. Toogood, S. (1994). "Organising Community Placements. Chapter 10 in McGill, P., Mansell, J. (Eds) "Severe Learning Disability and Challenging Behaviour: Designing high quality services. London, Chapman & Hall.
Remington, B. (1993) "Challenging Behaviour in People with Severe Learning Disabilities: Behaviour Modification or Behaviour Analysis?" In Kiernan, C. (Ed) "Research to Practice? Implications of Research on the challenging behaviour of people with learning disability. B.I.L.D. Publications, Clevedon.
Toogood, S., Bell, A, Jaques, H., Lewis, S., Sinclair, C., Wright (1994,a) "Meeting the Challenge in Clwyd: The Intensive Support Team (Part 1) British Journal of Learning Disabilities Vol. 22, P18-24.
Toogood, S., Bell, A., Jaques, H., Lewis, S., Sinclair, C., Wright (1994,b) "Meeting the Challenge in Clwyd: The Intensive Support Team (Part 2). British Journal of Learning Disabilities. Vol. 22, P46-52.