Implementarea unui program de activităţi socio-recreative la pacienţii internaţi cu tulburări psihice. Studiu-pilot

Introduction

Mental disorders, especially the severe mental disorders, alter the patients’ normal functioning and their quality of life, resulting in an increased level of psychological distress. During hospitalization, due to the fact that these feelings may increase, many patients have the tendency to isolate themselves or spend most of their time engaging in unproductive behaviors that slow down their recovery.

The development of a more active social environment in psychiatric wards could improve clinical outcomes for inpatients⁽³⁾, while enhancing their self-motivation, mental health, and the satisfaction of needs such as competence, autonomy and relatedness⁽⁵⁾, yet little time is allocated to developing socio-recreational programs, according to research⁽⁶⁾.

The Self-Determination Theory states that the most complete representations of humanity show that people are curious, self-motivated, striving to learn and to acquire new skills⁽⁵⁾. However, it is also undeniable that some people tend to forego growth and responsibility⁽⁵⁾, and suboptimal functioning could also be noticed among patients admitted to psychiatric wards.

Motivation refers to energy, direction, persistence and equifinality, while intrinsic motivation is defined as the inherent tendency to seek novelties and challenges, to expand and exercise one’s capabilities, to explore and to learn⁽⁵⁾.

People with intrinsic motivation show more interest, enthusiasm and confidence, which manifests as increased performance and persistence (Fishback and Woolley, 2022) or creativity⁽²⁾, but also as a higher self-esteem⁽⁴⁾.

In terms of psychiatric disorders, intrinsic motivation fully mediates the relationship between patients’ functioning and negative symptoms in schizophrenia⁽⁷⁾, while the lack of motivation is correlated with limited recovery after a psychotic episode⁽¹⁾. Furthermore, intrinsic motivation predicts a less severe post-treatment depression and a greater likelihood of remission⁽⁸⁾.

Self-Determination Theory investigates peoples’ inherent growth tendencies and their innate psychological needs (need for competence, relatedness and autonomy) that underlie their self-motivation and personality integration, as well as the conditions that favor these processes, Ryan and Deci (2000) arguing that social environments can facilitate or prevent intrinsic motivation by supporting or thwarting people’s innate psychological needs⁽⁵⁾.

Thus, the aim of this study is to investigate whether the implementation a socio-recreational activities program in the psychiatric ward could increase the patients’ motivation and well-being. An exploratory study with a mixed, quantitative and qualitative design, was conducted to investigate the effectiveness of the socio-recreational activities program by assessing patients’ intrinsic motivation, as well as their subjective experiences following their participation to those activities.

Method

Female patients of the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry, Sibiu, aged between 18 and 65 years old, diagnosed with a mental disorder ranging from affective disorders to psychotic disorders, were included in this study. The participants diagnosed with neurocognitive disorders and those unable to participate to the socio-recreational activities due to bed immobilization or difficulties in concentration were excluded.

Out of the 46 patients who participated in this study, 22 patients were assigned to Group 1 – the affective disorders patients’ group, while 24 patients were assigned to Group 2 – the psychotic disorders patients’ group.

The socio-recreational activities program

During six months, a socio-recreational activities program was implemented in Ward II of the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry from Sibiu. The aim was to develop a rich social environment that could facilitate de development of patients’ personal growth, competence and well-being. The weekly program included:

• Fitness

• Dancing

• Arts and crafts

• Painting

• Baking

• Group counseling.

Instruments of evaluation

To evaluate the patients’ subjective experiences regarding the socio-recreational activities, the Intrinsic Motivation Inventory Scale⁽⁵⁾ was used. This self-report questionnaire contains seven subscales and 45 items, three of which are open-ended questions.

The participants were asked to evaluate on a 7-point Likert scale (1 – not at all true; 7 – very true) their interest and enjoyment during the activities, their perceived competence and effort, their perceived value and usefulness of the activities, the pressure and tension felt during activities, and relatedness to others.

Data collection

The participants were recruited in the “Dr. Gheorghe Preda” Clinical Hospital of Psychiatry, Sibiu. They were informed about the goal of the study, their rights to anonymity and data confidentiality, about the fact that they can refuse to participate and about their right to withdraw from the study at any point. The data were collected in a pencil-paper format after taking part in the socio-recreational activities. The questionnaire took about 30 minutes to complete.

Data analysis

Both quantitative and qualitative methods were used. The 42 items of the Intrinsic Motivation Inventory⁽⁵⁾ provided numerical data that were analyzed using the SPSS software, and the three open-ended questions provided qualitative data used in the thematic analysis.

Results

Quantitative results

There are no significant differences between the two groups (affective disorders and psychotic disorders) regarding patients’ interest and pleasure in participating to the socio-recreational activities

(M_{psychotic disorders} = 6.7857; M_{affective disorders} = 6.7017),
as well as their perceived value and utility
(M_{psychotic disorders} =6.8261; M_{affective disorders} = 6.7273), both representing important aspects of intrinsic motivation (Figures 1 and 2).

There is a significant positive correlation between patients’ perceived competence and the utility of the activities [r_s = 0.437(44), p>0.05], interest [r_s = 0.326(44), p>0.05] and the effort they took [r_s = 0.423(44), p>0.05].

There is a significant negative correlation between perceived pressure to participate and patients’ interest regarding the activities [r_s = -0.303(44), p>0.05], the effort they took [r_s = -0.340(44), p>0.05], and the value and utility of the activities [r_s = -0.477(44), p>0.05].

Qualitative results

The open-ended questions of the Intrinsic Motivation Inventory provided insights into the patients’ subjective experiences regarding the socio-recreational activities, especially around the benefits and importance of these activities. Their answers were coded and analyzed following the thematic analysis procedure. Three main themes were identified: personal development and self-knowledge, mental and physical health, relaxation and creativity.

Personal development and self-knowledge

During group counseling, the patients had the opportunity to interact with other patients who were going through similar episodes of mental disorders and, according to one patient, the sessions were beneficial because “they help us to think positively, to get over difficult moments in our life easier” (Patient 7; paranoid schizophrenia) and important because they help with “getting to know ourselves, to develop” (Patient 10; bipolar affective disorder) and to “stop thinking that only your problems are important” (Patient 12; persistent affective disorder). Through these sessions, another patient had the opportunity to learn from others “how they overcame their problems” (Patient 15; severe depressive episode). According to a participant with the diagnosis of schizophrenia, these sessions could help her become “more optimistic, to know that after problems things improve” (Patient 13). Another patient, diagnosed with recurrent depressive disorder, believed that group counseling sessions helped her “trust myself more” (Patient 4).

Physical and mental health

Patients considered that the fitness and dance classes were beneficial for “a better mental state” (Patient 30; paranoid schizophrenia) and important “for optimism, energy” (Patient 38; acute psychotic disorder) and “for health and muscle toning” (Patient 26; moderate depressive episode). Patient 28, with a diagnosis of hebephrenic schizophrenia, believes that the fitness and dance classes can improve self-confidence: “it could help me feel livelier, regain my self-confidence”, while the baking classes have been considered beneficial for “well-being and harmony” (Patient 24) and important because they could help patients “return to normality” (Patient 23; moderate/severe depressive episode).

Relaxation and stimulation of creativity

The patients consider that the arts and crafts classes were beneficial for “stimulating creativity, for relaxation” (Patient 39; paranoid schizophrenia) and for “letting me express my emotions” (Patient 47; paranoid schizophrenia), the patients also mentioning the fact that the classes were “a splash of color on a rather dark sky” (Patient 40; recurrent depressive disorder). Moreover, these arts and crafts classes helped patients discover “skills I didn’t think I had” (Patient 39; paranoid schizophrenia). The baking classes were also considered a source of relaxation, a patient diagnosed with psychotic disorder mentioning that “it relaxes you, it makes you forget that you are in the hospital; you feel like you are at home or at a friend’s place, like on a holiday” (Patient 19).

Discussion

People may be motivated to engage in an activity either because there is an external reward, or because they value an activity, because they find it interesting, or due to a sense of personal commitment, these being aspects of intrinsic motivation⁽⁵⁾. The results show that patients scored high on the interest and pleasure and value and usefulness of the activities subscales, both aspects of intrinsic motivation.

Although experiencing different symptomatology, intrinsic motivation does not vary significantly between patients with affective disorders and those with psychotic disorders in terms of interest and enjoyment of activities and the value and usefulness of activities, indicating that such activities can be successfully implemented in both groups.

Patients need to feel competent and giving them access to engaging socio-recreational activities could increase their interest, as well as their intrinsic motivation for that activity. Patients who consider the activities more valuable and useful, those with a higher level of interest and those who made a greater effort perceive themselves as more competent, according to the results.

Feelings of competence will not enhance intrinsic motivation unless accompanied by a sense of autonomy. Thus, the results reveal that the patients who feel less pressure to participate in activities have a higher level of interest, exert a higher level of effort and consider the activities more valuable and useful.

Conclusions

Intrinsic motivation among patients with a diagnosis of affective disorders, as well as psychotic disorders, which is required for a faster recovery^(1,7,8), is very high after participating in socio-recreational activities.

In order to increase the level of perceived competence in patients, it is necessary to select socio-recreational activities that patients consider valuable and useful. Thus, they will feel less pressured to participate and will show more interest.

Patients’ inherent tendency to extend their capacities, to explore and to learn will flourish if the circumstances allow it, and the implementation of socio-recreational activities programs in psychiatric wards favor the development of an active social environment that offers patients the opportunity for development, relaxation, creation, improvement of mental and physical health while facilitating the satisfaction of competence, autonomy and relational needs, as well as the development of intrinsic motivation which is associated with a faster recovery from an episode of mental illness⁽⁸⁾.

Limitations of the study. The participants in this study were limited, therefore another study could replicate the results on a larger number of subjects, including male subjects. Another limitation of this study is the measuring method, a self-report questionnaire that could register errors related to the honesty of the answers.