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 Table of Contents  
LETTER TO EDITOR
Year : 2017  |  Volume : 33  |  Issue : 4  |  Page : 375-376

Rehabilitation in a person with low average intellectual functioning: A case report


1 Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Belgaum Institute of Medical Sciences, Belagavi, Karnataka, India
3 Department of Psychiatry, Psychiatric Rehabilitation Services, National Institute of Mental Health and Neuro Sciences, Bengaluru, India

Date of Web Publication17-Nov-2017

Correspondence Address:
P C Ashfak Ahamed
Centre for Addiction Medicine, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.218599

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How to cite this article:
Ashfak Ahamed P C, Sujai R, Pathak A, Sivakumar T. Rehabilitation in a person with low average intellectual functioning: A case report. Indian J Soc Psychiatry 2017;33:375-6

How to cite this URL:
Ashfak Ahamed P C, Sujai R, Pathak A, Sivakumar T. Rehabilitation in a person with low average intellectual functioning: A case report. Indian J Soc Psychiatry [serial online] 2017 [cited 2022 Jan 26];33:375-6. Available from: https://www.indjsp.org/text.asp?2017/33/4/375/218599

Sir,

Psychiatric rehabilitation is a discipline utilising techniques and strategies designed to meet needs of persons with psychiatric disability. This case report describes rehabilitation assessment, collaborative care intervention, and road to recovery for a client who has a low average intellectual functioning (IQ = 86),[1] diagnosed with specific developmental disorder of scholastic skills (F81) and mental and behavioural disorders due to use of tobacco-harmful use (F17.1) according to International Classification of Diseases-10.[2]

Mr. AG, a 24-year-old single male was referred to psychiatric rehabilitation services with complaints of lack of interest in academics, smoking, and anger outbursts for 3 years.

National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, provides a specialised service, Services for Enhanced Recovery with Intensive and Continued Engagement (SERWICE) to provide an outpatient, family assisted and comprehensive rehabilitation for a person with severe mental disorders.[3] SERWICE assessment pro forma assesses domains of current living situation; current symptoms and its influence on functioning; medication side effects including severity and interference with functioning; comorbidity including psychoactive substance use; caregiver's understanding about illness and priority issues of concern; previous pharmacological management and its outcome; ability in basic daily activities and instrumental activities; client's social and occupational functioning; cognitive problems; attitude and expressed emotions of family members; and level of disability.

Mr. AG's family hails from a middle social economic status. He is the youngest of three siblings. His parents are retired bank employees and are his caretakers. His elder siblings are well-educated and are working out of Kerala along with their family.

Mr. AG'S family was aware of his intellectual disability. His mother had taken immense effort to train him to clear school examinations. After higher secondary school, they opted for a graduate course with more practical lessons as it would be easy for him. He was enrolled in a bachelor's degree in performance arts course, but his attendance was irregular. He was dropped out of internship in computer diploma course as he could not complete his project.

He had an erratic schedule of waking up, having food, and spend a lot of time watching TV. When parents criticised him, he became angry, either shout at them or stop talking to them. He smoked 3–4 cigarettes per day for the last 6 years and stole money for it. He was in precontemplation stage of motivation for quitting cigarettes.

Based on assessment, the following issues were identified for intervention: Lack of trust between client and parents, parental expectations which were not in sync with client interest and lack of motivation to enhance his abilities. There was a need to engage with the client and family regularly to resolve the issues. He was offered day care facilities to reduce face to face contact with family. Besides, day care would offer a nonjudgmental environment, expose him to rewarding activities and help him to have an activity schedule. Client and family agreed for day care and psychosocial interventions. Informed consent was taken from them as per hospital policy.

Psychiatric rehabilitation services, NIMHANS, have a day care facility with 15 vocational sections having a range of activities including art therapy, family recreation activity, and music and movement therapy.

The initial emphasis was to establish and strengthen rapport with the client. As the client was not keen to discuss about substance use, it was decided to take it up later as it could hurt the therapeutic alliance. He was encouraged to explore various facilities in day care centre and take up activities of his choice. He chose computer section as he was interested in it and plastic moulding section as the instructor spoke his mother tongue. He also attended yoga therapy for an hour daily.

Family members were advised not to criticise the client at home and to share their concerns with the therapist. In family sessions, they were psycho-educated about the nature of problems and the ways of handling it. His brother and sister in law were helpful and would aid parents to handle problematic situations when they arose.

The instructors updated issues regarding the client and therapist requested for their observation. Feedback was periodically collected from nursing staffs, vocational section instructors, and hospital attendants regarding his behaviour in different situations. As the client was good at basic computer skill, the instructor gave him opportunities to teach other clients. He was comfortable in sharing his feelings and concerns with plastic moulding section instructor. He actively participated in family recreation activities in day care. The day care centre staffs were nonjudgmental, allowing him to do activities of his choice, helping him in the process and reinforce positive behaviour. Earlier his interaction was restricted within family members and classmates. Gradually, he started interacting with other clients in day care and made them friends. As he liked coming to the day care centre, he was regular in attendance which helped him to organise his daily schedule.

When he was asked to make a three-dimensional design of a 2 floor home, he worked hard at his home over a weekend to design it. He also designed a visiting card for his father. The family was happy with the efforts he was putting in. They were asked to appreciate his efforts and were encouraged to take him out to picnic spots during weekends.

Over a period of time, the client was also amenable for motivation enhancement therapy. Strategies to handle craving were discussed. The client quit smoking without any pharmacological assistance. Consequently, he stopped stealing money. In the family, criticism was gradually replaced with warmth and positive regard for his efforts.

As a part of vocational counselling, therapist discussed about client's interests and future job prospects. He expressed interest in becoming a cricketer, driver, or an employee in software-related field. He was motivated to find out job prospects in these fields. After seeking opinion from various people, he decided that he would play cricket as a hobby rather than take it as a profession. His family discouraged him from becoming a driver as they felt it was not suitable for their social status. Client decided to resume his internship in animation back at home. Family members were willing to back his plans as they had observed positive changes in day care for 2 months.

On follow-up of 3 months and 6 months, client had successfully completed internship. He started searching for jobs in newspapers and attended interviews. After a few interviews, he got a job as a salesman in a reputed garments firm with a monthly salary of Rs. 7500. The family was happy with his efforts and encouraged him to take up the job discarding the issues of low salary and social status.

He made friends in his workplace and gifted clothes for his family with his salary. He was satisfied with the job and was able to fulfill his responsibilities. The family members got to know that the client started smoking with his salary and were concerned about it. They were requested to follow-up with nearby psychiatrist or visit our facility for management.

In this case, emphasis was given to principles of recovery.[4] The client's priorities were given importance, and he was empowered to choose from different options. Family interventions helped in improving home environment and sense of belonging. Coordination between therapist, vocational instructors, nursing staffs, and family helped in achieving desired goals. His strengths were identified, and rewarding opportunities were provided. This opened up avenues for gaining respect from colleagues and family. The interventions enhanced hope of the client who could chart out of a life course of his choice independently.

The case report shows that day care is a useful tool in rehabilitation for patients with psychiatric disorders. Apart from training them in vocational skills, it can offer a therapeutic holding environment to engage clients in the rehabilitation process and help them progress on the road to recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Weiss LG, Saklofske DH, Prifitera A, Holdnack JA. WISC-IV Advanced Clinical Interpretation. USA: Academic Press, Elsevier; 2006.  Back to cited text no. 1
    
2.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: WHO; 1993.  Back to cited text no. 2
    
3.
Sivakumar T, Soundararajan S, Waghmare A, Basavaraj C, Gandhi S, Udgiri S, et al. Services for enhanced recovery with intensive and continued engagement (SERWICE): An outpatient psychiatric rehabilitation model from India. Asian J Psychiatr 2014;11:84-5.  Back to cited text no. 3
[PUBMED]    
4.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA's Working Definition of Recovery. 10 Guiding Principles of Recovery; 2012. Available from: http://www.store.samhsa.gov/shin/content//PEP12-RECDEF/PEP12-RECDEF.pdf. [Last accessed on 2015 Jun 02].  Back to cited text no. 4
    




 

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