The role of arts therapy in exploring sexuality and relationships among clients with impaired mental capacity

As professionals and as people, we need to become comfortable talking about sex and relationships because our silence on this subject heavily impacts the lives of those living with a brain injury who may be considered to have impaired ‘mental capacity’.

And as therapists, these is-sues are becoming more and more a part of our sessions, and we need better, more transparent, approaches to deal with them. This is a grey area.

All those involved in a client’s case, including court deputies and case managers, need greater awareness around this complex issue as our level of understanding effects their lives.

Clients want, need and have a right to access appropriate sexual experiences and interactions, whether that be alone or with someone else. Guidance is required to enable people to live as much of a full life as possible.

But of course, there is a safeguarding issue, as stats indicate people with cognitive or executive function issues are seven times more likely to suffer sexual abuse than anyone else, so there is a clear need for protection and safeguarding for vulnerable people.

Issues continue to arise surrounding the role of the case managers and court deputies in such cases, as their aim is to help people stay empowered whilst being protected.

I was told of a 25-year-old woman who suffered a TBI, who was mostly bed-bound due to her condition and was also obese as a result. She requested that the support worker purchase a vibrator for her. The woman had full mental capacity.

The support team initially flagged this as a safeguarding issue to the case manager, who confirmed that it certainly was not a safeguarding issue.

The support team did not know what to do with the woman’s request and felt very uncomfortable, even though the woman would be using the vibrator alone, in her own bedroom etc.

Given her presentation/condition, it was likely that using the vibrator was going to provide pleasure and relaxation, and potentially be one of the only things that would bring her a sense of wellbeing.

This is just one example of many that highlight the need for a better approach towards the subject. Personalised care means supporting each individual as an individual. The right interventions can help to ease these seemingly uncomfortable conversations/situations.

Implementing the creative arts therapies into a person’s case may offer an effective means to help case managers support their clients around consent and relationships, and could help care staff have conversations about the impact of decisions made on the client’s behalf concerning their lives.

Dramatherapists, for instance, can use role-play to help clients understand the feelings of others as well as how their actions may affect those around them, along with providing a means to explore/discuss what it may feel like to start a relationship with someone.

Art Therapists can help clients to understand how the world may see them, or how they may see themselves, helping the client’s level of insight. This can be in the context of their personal safety and their possible vulnerability in the world around relationships.

The Journal of Head Trauma Rehabilitation reported, “Dramatherapy helps people with TBI’s explore and communicate their feelings and desires related to sexuality and relationships.”

Participants reported feeling more comfortable discussing these topics after engaging in dramatherapy. For example, a 19-year-old male with developmental delay was referred by their parent to Chroma to gain a better understanding about boundaries in relationships. He enjoyed fantasy stories, so the drama-therapist chose this as a focus in treatment.

The client grew to understand issues by identifying with the characters in the situation because stories give access to ideas and images not easily spoken about through language.

The American Journal of Occupational Therapy also found that Art Therapy helps individuals with TBIs express their emotions and improve their self-esteem.

Participants reported having more positive experiences in their relationships.

A 24-year-old woman who developed an Acquired Brain Injury (ABI) was referred to Art Therapy to explore areas of her life that were important to her – including relationships, family and the future.

Art Therapy provided a therapeutic space to think about issues around sex and relationships, which may include loneliness. Having a boyfriend and starting a family was a strong wish for her. With diminished inhibition, she would often ask someone “Do you want to have sex?”

Art Therapy explored the space before this question – getting to know someone, and rejection, as well as helped her to process her frustrations around the safety that her support staff maintained.

According to the Care Quality Commission (CQC) “Sexuality encompasses a person’s gender identity, body image and sexual desires and experiences. This means people can have needs relating to their sexuality, regardless of their age, mental capacity, or personal history.”

Baker (2001) also stated that, with regards to sex, there was a danger that the imposition of a higher standard for mental capacity may discriminate against people with a mental impairment.

And yet, mental capacity is at the forefront of this issue.

The Creative Arts Therapies can help clients improve cognitive function whilst engaging in a fun, creative activity. They provide a non-threatening, safe environment for the client to process their thoughts and feelings, whilst gaining a better understanding of their situation.

Creative Arts Therapies are able to highlight every-day abilities through creativity.

Dramatherapists and art therapists can use their medium to help clients understand the sequence of, for example, setting up a date; starting a conversation with someone through role-play, or through creating art using a learned sequence.

Both means have the ability to discover if the client has the capacity to learn and if they do, the use of Arts Therapies in this context gives hope to the clients who need it, in that intimacy may be a possibility for them in their future.Arts therapists need to be prepared to face these situations, and Chroma’s continual professional training ensures our therapists are ready for the challenge.

At this point in time, there is no clear cut resolution but, the use of arts therapies in cases such as these, does help case managers and court deputies better determine a balance between empowerment and protection which will hopefully help many people considered to have impaired mental capacity, to lead healthy, intimate lives.

References: Levy, J. M., DePompei, R., Gillette, Y., & Geist, R. (2016). Exploring sexual identity, intimacy, and relationships after traumatic brain injury: A dramatic exploration. Journal of Head Trauma Rehabilitation, 31 (2), E42-E48.Sohlberg M. M., McLaughlin, K.A., Pavese, A., Heidrich, A., & Posner, M.I. (2007). Evaluation of at-tention process training and brain injury education in persons with acquired brain injury. Journal of Clinical and Experimental Neuropsychology, 29 (2), 151-165.Baker, J., & Menken, M. (2001). Autonomy, the good life, and controversial choices. Cambridge Quarterly of Healthcare Ethics, 10 (1), 55-64