Recreation for Psychosocial Rehabilitation of Clients with Mental Health Disorders: A Retropective Review.

Recreation is considered as an important part of rehabilitation as it increases cognitive ability improves social and communication skills among clients with mental health disorders. As part of Psychiatric Rehabilitation Services NIMHANS, weekly recreational activities are conducted for clients with mental health disorders. A retrospective file review of clients' feedback (who participated offline and online) about the recreation session was conducted. Thematic analysis was carried out to analyze the data. Reasons and Benefits of participating in recreation challenges faced, and changes clients would want to bring in the sessions were the themes that emerged. There were differences in the structure of recreation activity conducted in online and offline mode. Overall clients were happy and interested to participate in recreation activities. Recreation should be an integral part of psychosocial rehabilitation for clients with mental health disorders.

Introduction

Recreation is a "skill that results from freely chosen participation in physical, social, intellectual, creative and spiritual pursuits, that enhance an individual’s and the community’s wellbeing" [1]. It is based on the idea of increasing a person’s independence and ability to function through participation in creative arts, dance, sports, adventure programs, puzzles or logic games. It is also considered an integral part of a holistic approach [2, 3]. Some of the many cognitive domains that recreation can enhance include problem-solving ability, goal-setting skills, and ability to follow directions, attention, memory, and improved concentration [4]. It also provides various socialisation benefits such as improvements in social confidence, communication skills, reciprocal relationship skills, and other interpersonal skills. The importance of recreation at different stages of life and the difficulties of families in accessing age-appropriate recreational facilities or activities is important when planning recreation activities. A research study conducted in the United Kingdom (UK) reported that men and women military veterans with Post Traumatic Stress Disorder (PTSD) who participated in a group outdoor recreational activity showed improvement in their psychological wellbeing [5]. A study of interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia showed that the use of simple and cognitively inspiring activities might help resolve delirium [6]. Group cognitive behaviour therapy and group recreational activity interventions have also been observed to be equally beneficial to participants in increasing their quality of life.

At the Psychiatric Rehabilitation Services (PRS) NIMHANS, recreation is considered as an essential activity for the psychosocial rehabilitation of clients with mental health disorders. The purpose of conducting the recreation activity is to engage the clients, improve their social functioning, and promote recovery. The Rights with Persons with Disability Act (RPwD) Act 2016, Chapter V (Sects. 29 and 30) also states that ‘Government and the local authorities should take measures to promote and protect the rights of all persons with disabilities to have a cultural life and to participate in recreational activities equally with others’ [7]. As there are no studies that have looked at the benefits of recreation and its contribution to the recovery of clients with mental health disorders in the Indian context, this paper was conceptualized. The specific aim of this study was to understand the need as well as the benefits of recreation, from the client's perspective.

Methodology

Adult clients diagnosed with mental health disorders as per ICD 10 and those who were registered as day-boarders with Psychiatric Rehabilitation Services (PRS) NIMHANS, formed the sample of this study. A retrospective file review of the last 2 years (2019–2021) of all clients who attended the recreation sessions at Psychiatric Rehabilitation Services was conducted. A total of 35–40 clients had attended the recreation sessions in the last 2 years. Out of these, clients (n = 11; seven attended offline recreation sessions, and four attended online sessions) who had provided significant qualitative feedback about the recreation session and whose statements had been recorded (written) in their respective hospital files were considered for this study.

The recreation activity was conducted every Saturday except the second Saturday from 2 to 3 pm (1 h). While conducting the offline sessions, around 35–40 clients used to participate and around 10–12 clients participated in the online sessions. The participation was open and was conducted in group format. Purpose of conducting the recreation activity was to engage clients, and help improve their social functioning and recovery. The recreation activity was conducted weekly by postgraduate mental health students posted to PRS in the language known to the majority of the group of clients (mostly, English and Kannada or English and Hindi). If some of the clients did not understand the language or activity, the help of the clients’ caregiver or family member was taken to help engage them in the session. Post-COVID pandemic (from August 2020 onwards) recreation sessions were conducted online and there was a difference in the type of recreation activities and games played online vs offline (more online mental games versus offline physical games). Different kinds of recreational activities were conducted during the 1-h online session every week such as finding the odd one out, finding the difference between pictures, identifying the celebrities hidden behind the masks, identifying the symbols or logos, singing songs, dancing, identifying the number of items or animals from a single picture, collecting household items with specific colours. During the offline sessions, physical games like bowling, musical chairs, etc. were played and the clients had a choice about which activity they wanted to participate in. The recreation activities were planned at easy-medium difficulty level so that all categories of participants including persons with intellectual disability could participate actively in the sessions.

Feedback collected about the recreation sessions was noted in the clients’ respective hospital files. The feedback was collected orally at the end of every session, with the help of a semi-structured schedule by the postgraduate mental health students posted to PRS who conducted the recreation sessions weekly. The data was manually collected as the questions were limited and the data collected was not huge [(technique of written note taking was maintained while collecting data by two of the authors of this paper (MJ and SA)]. The feedback of clients who had mild to moderate intellectual disability was collected with the help of their caregiver.

This data was manually content analysed following a six-step approach to thematic analysis proposed by Braun and Clarke [8]. The thematic analysis was carried out mainly by two of the authors of this paper (MJ and SA). The primary author (AJ) helped in clearing any contentious differences in thematic analysis between the former two authors.

Results

A total of four themes and 14 sub-themes were elicited from the feedback provided by the clients. The sociodemographic characteristics of the clients were: seven (63%) were male and four (37%) were female. The mean (SD) age of the clients was 34.45 (12.04) years. Majority of them were diagnosed with schizophrenia (n = 4) or Intellectual Disabilities (ID) (n = 4), two of them were diagnosed with Bipolar Affective Disorder (BPAD) and one of them was diagnosed with cerebral palsy and BPAD. The themes, sub-themes, and respective quotations are tabulated in Table 1.

Table 1

Themes and sub-themes

Themes	Subthemes	Illustrative quotes
Reasons for participating in a recreation activity	Recommendation of doctor For playing games For making friends	"Doctor advised me to participate in recreation" (Mrs L, 45 years) "Playing games in recreation activity made me more interested to participate" (Mr P, 35 years) "I used to enjoy a lot as I got many friends from here." (Mr M, 25 years) "Recreation is very helpful for me…and games I like the most" (Ms A, 22 years)
Benefits of participating in recreation	To learn new facts/trivia To feel energized/ refreshed To feel involved To feel happy To socialize with a group of known people	"The questions which I don't know will be asked in the quiz, so I can learn something from it." (Ms A, 22 years) "I feel refreshed if I participate in recreation." (Mr A, 27 years) "I feel happy and more involved with while participating in recreation activity " (Mr S, 38 years) "I will miss the PRS team and my friends if I do not attend recreation." (Mr A, 27 years)
Challenges faced in participating (offline and online) in a recreation activity	The quiz is difficult Inability to attend offline recreation Inability to understand language in which recreation session was taken Lack of knowledge in using online platforms/phones for participating in sessions	"The way you ask the questions… (it seems) seems very easy but answers are very tough; as much as possible I will try to answer" (Mrs L, 45 years) "it's difficult to travel for me to participate in recreation activity because my house is far away from PRS" (Mr P, 35 years) "Since it is made online, I miss playing games like ball passing, dancing, running." (Ms. A 22 years) "Language is a bit difficult to understand, I would be happy if you speak in my language" (Mr S, 38 years) “I have a problem in joining the sessions online, sometimes the link you share does not work in my mobile phone and I do not know how to use the online platform or update the meeting app.” (Mr RA, 20 years)
Changes clients want in the recreation activities	No changes are required Reduce the difficulty level of the activities Inclusion of creative games Increasing time or frequency of sessions	"No changes. I like the way it is" (Ms A, 22 years) "If the questions are tough, the clients will get scared, if it is simpler, they will be more interested in participating in recreation activity" (Mrs L, 45 years) "More creative games which encourage all to participate" (Mr A, 27 years) "More time (hours) for recreation or twice in a week (sessions) would be great." (Mr S, 38 years)

Clients always had a positive attitude towards recreation either when approached to attend online or in face-to-face sessions. The challenges faced in conducting the recreation sessions using technology included network issues, unfamiliarity of clients in using online video streaming platforms, unavailability of smartphones with clients from lower socio-economic backgrounds, etc. One of the main challenges experienced in conducting offline sessions, was lack of space for conducting the outdoor activity.

Discussion

One of the main reasons for the success of the recreation activity was “client’s participation.” The feedback from the clients showed that they perceived the benefits of attending the recreation sessions such as opportunities for socialization, experiencing positive emotions like happiness, gaining information, feeling meaningfully engaged in activities, etc. Research has shown that people who participate in sports clubs and organised recreational activities enjoyed better mental health and were more alert, and more resilient against the stresses of modern living. Recreation was also seen to increase self-confidence, morale and life satisfaction.

Traditionally in PRS the recreation sessions were conducted in person, face-to-face. However, due to the current situation of COVID 19, the use of technology was adopted to conduct the recreation sessions. Even though care was taken to conduct the session in languages known to the majority of the clients in the session; conducting the session in the vernacular language known to each client in a multicultural India was challenging. So, in case of a large number of clients participating in the session, multiple translations needed to be done or smaller recreation groups based on language need to be conducted. Further, though the games and activities conducted were simplified keeping in mind the different cognitive abilities of the clients, some of them felt that the games were difficult to play and others with better cognitive abilities felt the games were childish and not stimulating enough. In future, break-out rooms can be considered for people with similar languages or interests to improve the recreation activity and participation.

Recreation is an important part of rehabilitation, which has been acknowledged in the RPwD Act 2016 and in research. The National Disability Fund under the RPwD Act 2016 has allocated funds for conducting and supporting recreational activities for Persons with Disabilities (PwD’s) [7]. This provision is a step towards encouraging organizations to conduct recreational activities for PwDs across India. Recreation plays an important role in enhancing the mental capabilities of people with mental illnesses. Unfortunately, while there are activities and opportunities for recreation for PwD’s, these are insufficient and often persons with mental health disorders are not consciously included.

The limitation of this study is the lack of triangulation of the qualitative data collected, as this the study was a retrospective analysis of information collected for service enhancement. In addition, the interaction between the clients reduced significantly during the recreation sessions due to the online method; most clients interacted with professionals who conducted the sessions and not with each other. Further, some of the clients were not able to focus on the screen/camera for the 1-h duration of the session effectively. Due to this, the duration of the recreation session was maintained at 1 h as compared to one and a half or 2-h sessions that used to be conducted when it was conducted in-person. The researchers also faced language barriers for interviewing the respondents; which was overcome by conducting the interview with the help of other postgraduate students of PRS who knew the client’s language. Another limitation of this study is that the feedback was collected from a very small subgroup of the total clients. To understand the effectiveness of recreation, the study needs to be conducted with a larger sample of clients.

This paper focused on the need and benefits of general recreation activities for persons with Mental Health Disorders (MHD). Specific activities such as dance, drama, music, sports etc., as recreational activities need to be researched and tested for their efficacy for improving recovery and quality of life of clients in a larger sample. Certain comparison studies regarding whether online or offline recreation is more effective can also be conducted. This would help advocate for the importance of recreation in the overall recovery of the client with MHD.

Conclusion

Recreation is an important need of clients with MHDs as it helps them to be engaged, be happy and provides a platform for socialization; irrespective of whether it is conducted online or offline. However, studies to test the effectiveness of specific recreation programmes need to be designed and implemented in the future.