Journal of Physiotherapy 63 (2017) 168–174

Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys

Research

Limited interface between physiotherapy primary care and people with

severe mental illness: a qualitative study
Samantha Lee a, Flavie Waters b,c, Kathy Briffa a, Robyn E Fary a
a
School of Physiotherapy and Exercise Science, Curtin University; b Clinical Research Centre, Graylands Campus, North Metropolitan Health Service Mental Health; c School of
Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia

K E Y W O R D S A B S T R A C T

Physiotherapy Questions: How do mental health professionals perceive the role of physiotherapists in the care of people
Physical therapy with severe and persistent mental illness, and what factors do they perceive as influencing access to
Physical activity physiotherapy services? How do people with severe and persistent mental illness understand the
Mental health
potential role of physiotherapy in their healthcare, and what factors do they perceive as influencing
Severe mental illness
access to physiotherapy services? Design: Qualitative study. Participants: Twenty-four mental health
professionals and 35 people with severe and persistent mental illness. Methods: Interview schedules
were developed to explore participants’ understanding of physiotherapy, as well as barriers and enablers
to service access. Focus groups and interviews were conducted for each group of participants. Transcripts
were analysed using an inductive approach to derive key themes. Results: Both the mental health
professionals and the people with severe and persistent mental illness expressed a limited
understanding of the role and relevance of physiotherapy for physical health in mental healthcare.
Common barriers to service access were cost, transport and lack of motivation. Likewise, enablers of
reduced cost, provision of transport and education about physiotherapy to improve their understanding
were identified. The health system structure and perceived lack of mental health knowledge by
physiotherapists influenced referrals from mental health professionals. Consequently, education in
mental health for physiotherapists and integration of the service within mental health were identified as
potential enablers to physiotherapy access. Conclusion: Limited understanding about physiotherapy and
its relevance to physical health in mental healthcare among mental health professionals and people with
severe and persistent mental illness was found to be a key factor influencing service access. Limited
physiotherapy presence and advocacy within mental health were also highlighted. There is a need for
greater understanding about physiotherapy among stakeholders, and for physiotherapists to be well
equipped with skills and knowledge in mental health to facilitate greater involvement. [Lee S, Waters F,
Briffa K, Fary RE (2017) Limited interface between physiotherapy primary care and people with
severe mental illness: a qualitative study. Journal of Physiotherapy 63: 168–174]
© 2017 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Severe and persistent mental illness (SPMI) refers to mental
health disorders that are associated with high levels of disability,
with profound impacts on personal, social and occupational
functioning.1 These illnesses typically include disorders such as
schizophrenia, schizoaffective disorders, bipolar disorder and
major depression.2 People with SPMI experience higher morbidity
and mortality rates, with up to 20 years shorter life expectancy
than the general population.3 These morbidity and mortality rates
are largely attributed to poor physical health, rather than a direct
consequence of their mental illness.4 In view of this disparity in
physical health between the general population and those with
SPMI, there has been a shift in attention towards improving
physical healthcare for people with SPMI. This shift is highlighted
in the World Health Organization’s 2014 slogan ‘no mental health
without physical health as well’.4
A core principle of the World Health Organization’s initiative
has been promotion of a multidisciplinary approach to healthy
lifestyle through increases in physical activity levels and improve-
ment in diet.5,6 However, despite evidence supporting the benefits
and use of physical activity in the treatment and management of
people with SPMI, physical activity levels in this population remain
low.7 This discrepancy suggests a lack of translation of evidence
into clinical practice, which has been aptly summarised by
Bartels8(p10): ‘the greatest current barrier to increasing the life
expectancy of persons with serious mental illness is no longer a
knowledge gap – it is an implementation gap’.
Healthcare providers play a crucial role in translating evidence
into practice. However, a myriad of complex factors contribute to

http://dx.doi.org/10.1016/j.jphys.2017.05.014
1836-9553/© 2017 Published by Elsevier B.V. on behalf of Australian Physiotherapy Association. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 Research
the present gap in implementation in mental healthcare. At a
structural level, insufficient funding and lack of integration
between physical and mental healthcare services4 mean inconsis-
tent quality of healthcare and focus on physical [4_TD$IF]wellbeing. There is
a lack of consensus between service providers over the role of
various healthcare professionals in the management of the
physical health of people with SPMI, which thereby influences
service provision.9,10[7_TD$IF] National physiotherapy bodies have provided
guidelines and recommendations regarding the potential for
physiotherapists to improve both the physical and mental health
of people with mental illness.11,12
Physiotherapists should be in a prime position to positively
If so, what prompted you to do this?
influence the physical health of people with SPMI, through healthy
What determined your choice of physiotherapist?
lifestyle promotion and individualised physical activity pro-
grams,12 with support for physiotherapist-led physical activity
programs among people with SPMI consistent across the
literature.11–14 However, despite this compelling evidence sup-
porting physiotherapy involvement in mental healthcare, anec-
dotally, it appears that physiotherapists still play a minor and
unrecognised role as primary mental healthcare providers. This
raises questions about why their involvement is limited.
The purpose of this study was to investigate factors influencing
physiotherapy involvement in the treatment and management of
people with SPMI in Western Australia from the perspectives of
mental health professionals and people with SPMI.
Therefore, the research questions for this qualitative study
were:
1. How do mental health professionals perceive the role of
physiotherapists in the care of people with severe and persistent
mental illness, and what factors do they perceive as influencing
access to physiotherapy services?
2. How do people with severe and persistent mental illness
understand the potential role of physiotherapy in their
healthcare, and what factors do they perceive as influencing
access to physiotherapy services?
Method
Study design
This study used a qualitative approach employing both focus
group and individual interviews with mental health professionals
and people with SPMI. A qualitative approach was chosen to allow
thorough exploration of participants’ views, concerns and beliefs on
complex issues, which would not be attainable through quantita-
tive means.15 Focus groups were chosen as the main method, due to
added benefits of collective discussions and exchanging of views.16
However, individual interviews were conducted if necessary to
accommodate participants’ schedules. This study was reported in
accordance with the COREQ-32 criteria.17
Participants
Mental health professionals were recruited from the North
Metropolitan Health Service - Mental Health. This service provides
public mental health care and treatment for approximately
1 million people in Perth, Western Australia.18 To be eligible, the
mental health professionals had to have an influence on referral
processes or the authority to refer people with SPMI to
physiotherapists. The mental health professionals were recruited
via internal communication channels, including newsletters,
emails and word of mouth.
People with SPMI were recruited from the community. Study
details were disseminated through community advertising and
flyers at drop-in centres and hostels. To be eligible, volunteers were
required to be aged 18 to 65 years and have had a schizophrenia-
spectrum disorder or severe mood disorder diagnosed by a mental
169
Box 1. Stimulus questions used with the mental health
professionals.
 How are physical health issues of people with mental
illness addressed in your place of work?
 Do you think there is a role for physical activity and
exercise in the management of people with mental
illness?
 What is your understanding of the role of physiotherapists
in the treatment and management of someone with
mental illness?
 Have you ever referred a patient to a physiotherapist?
 Do you think physiotherapy might benefit your clients and
how so?
 What would help in referring people with mental illness
more frequently to community physiotherapists?
 Do you perceive any barriers in referring individuals with
mental illness to community physiotherapists?
health professional. Volunteers were only included after verifica-
tion of eligibility by their case manager or psychiatrist. Exclusion
criteria were a current acute episode of psychosis or the inability to
provide consent or communicate in English.
Data collection
An interview protocol was developed for each category of
participants, based on existing literature and the clinical experi-
ences of senior researchers (REF, KB and FW). Specifically, the
understanding of the role of physiotherapy in mental healthcare
settings, and perceived barriers and enablers in accessing
physiotherapy services for people with SPMI were explored.
Prior to data collection, training was provided to the primary
researcher (SL) who facilitated the focus groups. The training
included observations of focus groups involving people with SPMI.
A sleep therapy researcher led the training, with advisory support
from an experienced mental health researcher and clinician (FW).
Focus groups and individual interviews with mental health
professionals were conducted at their place of work. The stimulus
questions used with the mental health professionals are presented
in Box 1. Focus groups and individual interviews with people with
SPMI were conducted at Curtin University, or their respective
lodging or drop-in centre. The stimulus questions used with the
participants with SPMI are presented in Box 2. Focus groups were
scheduled to last for a maximum of 1 hour, whereas individual
interviews were not scheduled for a maximum duration. Interviews
were audio-recorded and transcribed verbatim. Subsequently, each
participant received a copy of the written transcript for verification.
Appropriate amendments were made where requested.
Participant characteristics were collected using paper ques-
tionnaires. For the mental health professionals, the recorded
characteristics were: gender, age, profession, area of work,
experience, and prior referrals to physiotherapy. For the people
with SPMI, the recorded characteristics were: diagnosis, duration
of illness, previous experience with physiotherapy, and prior
referral for physiotherapy.
Data collected during focus groups and individual interviews
were analysed using an inductive approach to identify themes.19
Focus groups and data analysis continued until data saturation was
achieved.19 Data saturation was defined as occurring when no new
themes were identified in consecutive focus groups.
Data analysis
The characteristics of the participants were summarised using
descriptive statistics calculated with commercial softwarea.
Qualitative data were analysed by the primary researcher (SL) in
170 Lee et al: Physiotherapy for people with mental illness

received physiotherapy referrals through a GP or mental health

Box 2. Stimulus questions used with the participants with
severe and persistent mental illness.
 In general, how would you consider your own general
health? What physical health problems do you have?
 How do your physical health problems affect your day to
day life?
 Does your mental health team or case manager know that
you have physical health issues?
 Have you tried, or do you want, to improve your physical
health? What have you tried?
 Have you ever had a referral to a dietitian,
physiotherapist, or occupational therapist?
 Thinking about physiotherapists, what do you think
physiotherapists do?
 How do you think physiotherapy can help in managing
your physical health?
 Do you consider yourself to be physically active?
 What sort of physical activity do you do and how much?
 Thinking about your current lifestyle, how does physical
activity fit in to your daily life or lifestyle?
 In your opinion, what might encourage you to consult or
ask for referral to physiotherapists for your physical
health?
 In your opinion, what are some things that might prevent
you from seeing a physiotherapist?
team.
Focus groups
A total of 10 and 13 focus group interviews were conducted with
mental health professionals and people with SPMI, respectively,
between February and June 2016. Of the mental health profes-
sionals, 22 were interviewed in focus groups and two were
interviewed individually. Among the people with SPMI, 34 were
interviewed in focus groups and one had an individual interview.
The duration of focus groups and individual interviews ranged
from 20 to 60 minutes.
Views of the mental health professionals
The themes and supporting quotes are summarised in Table 2.
Theme 1: General lack of awareness and understanding regarding the
role, scope of practice and relevance of physiotherapy in mental health
Although the benefits and importance of physical activity and
exercise for people with SPMI were recognised, few saw a role for
physiotherapy in mental health. Physiotherapy was often per-
ceived as relating only to specific injuries or musculoskeletal
problems. Reasons contributing to the current lack of understand-
ing were categorised into three subthemes (Table 2).

consultation with two other researchers (REF and KB). An inductive
analysis approach was used, with coding and categorising of the data
obtained into main themes and subthemes until no new themes
emerged.19 Themes were discussed amongst the research team to
reach consensus.
Results
Participants
A total of 24 mental health professionals and 35 people with
SPMI were recruited for the study. The characteristics of each
group of participants are presented in Table 1. Among the mental
health professionals, four (17%) had referred a mental health
patient to a physiotherapist. Among those with SPMI, 15 (43%) had
had previous contact with a physiotherapist. One participant
Subtheme 1.1: Lack of marketing of physiotherapy services within mental
health services
Mental health professionals spoke of the ‘lack of presence’ of
physiotherapy, unlike other services such as occupational therapy
that actively promote and educate mental health professionals on
service options available for people with mental illness.
Subtheme 1.2: Physiotherapy is a profession isolated from the mental
health service
Physiotherapy was not perceived to be part of the treating
multidisciplinary team. North Metropolitan Health Service – Mental
Health offers physiotherapy services as part of inpatient rehabilita-
tion, yet only five professionals were aware of this service.
Subtheme 1.3: Perceived lack of specialist mental health knowledge by
physiotherapists
Mental health professionals also perceived that physiothera-
pists lack the education and clinical experience that are specific to

Table 1
Characteristics of participants.

Characteristic Mental health People with severe and

professionals persistent mental illness
(n = 24) (n = 35)

Gender, n male (%) 18 (75) 21 (60)

Age ([5_TD$IF]yr), mean (SD) 44 (10) 39 (9)
Primary area of professional practice, n (%)
specialist nurse 11 (46)
social worker 5 (21)
occupational therapist 5 (21)
other 3 (13)
Current area of work, n (%)
outpatient 22 (92)
outpatient and inpatient 1 (4)
research 1 (4)
Clinical experience in mental health (yr), mean (SD) 19 (13)
Has previously referred to physiotherapy, n (%) 4 (17)
Schizophrenia spectrum disorder, n (%)
schizophrenia 23 (66)
schizoaffective disorder 4 (11)
Severe mood disorder, n (%)
bipolar disorder 4 (11)
major depression 2 (6)
other 2 (6)
Duration of illness since diagnosis [6_TD$IF](yr), mean (SD) 17 (9)
Previous experience with physiotherapy, n (%) 15 (43)
Received referral by healthcare professional for physiotherapy, n (%) 1 (3)
 Research 171

Table 2
Thematic responses of mental health professionals.

Theme 1: Limited awareness and understanding of the role, scope of practice and relevance of physiotherapy in mental health

Physiotherapy has always been one of those disciplines that I can’t . . . I can’t see, personally, that is compatible with mental health (M5)
You would think about dieticians or you would think about occupational therapy . . . I would think of those professions before I would think that physiotherapy was a place to
refer somebody. So I probably need educating about the role (of physiotherapy) (M9)
Because if you’re thinking physical activity you’re not thinking physio, you’re thinking more groups . . . exercise (M16)
Subtheme 1.1: Limited marketing of physiotherapy services within mental health services
A lot of occupational therapists . . . work with GP clinics to get referrals and work with mental health clients . . . But I’ve not seen the same with physiotherapy (M21)
Subtheme 1.2: Physiotherapy as a profession isolated from mental health services
We’re all North Metro but no one here . . . has heard about the hospital’s physio program (M23)
I think with physios in the hospital they sit in isolation so they’re not really part of the treating team per se . . . sometimes it looks from the outside it’s kind of well what can we
do to keep the patients amused for an hour . . . (M24)
Subtheme 1.3: Perceived lack of specialist mental health knowledge amongst physiotherapists
It would have to be an education for the physiotherapists themselves because they would have to understand the medications, they’d have to understand the side-effects of the
medications, they’d have to understand in depth a good history of the client, all aspects (M18)

Theme 2: Structural barriers influencing referral process and uptake of services

Subtheme 2.1: Limited funding capacity to address physical health problems

The OTs used to run a few groups here that would address weight management and exercise programmes or that kind of thing, but now that funding’s gone it’s been . . .
pushed over to the NGOs (M14)
Walking groups, all those sort of things which now we’ve lost all the staff and the funding and the facilities to do (M12)
Subtheme 2.2: Capacity and suitability of external services for physical health
The GP remains in most instances . . . the coordinator of care for that person (M11)
I suppose GPs might be out of their depths as well in terms of managing their complexities, multiple complexities (M13)
In referring a person with mental issues to a GP... you’re actually asking them to do a whole lot more work which they don’t like in the mental health area because to do it
properly requires a lot of input (M11)
I think, they’re the hub, as they [GPs] should be, but I don’t think the communication going out from them is very good unless there’s a severe problem . . . communication
flows one way a lot of the time (M20)
Subtheme 2.3: Receptivity of external services
But certainly, the lack of opportunities for mental health clients is phenomenal (M5)
It becomes problematic in terms of the public system because there aren’t many around and the hospital itself isn’t very receptive to referrals that we might send (M4)

Theme 3: Patient-specific barriers influencing referral processes

Subtheme 3.1: High associated cost

Money’s probably one of the largest barriers for our clients (M15)
A large proportion are on disability support pensions so they’ve got quite a small income and therefore can’t afford a lot of medical services unless they are covered by Medicare
or some form of funding (M6)
Subtheme 3.2: Transport
Physically getting there . . . we’ve got a lot of people who haven’t got transport, so that’s a problem as well (M11)
Subtheme 3.3: Factors associated with the mental illness
We work with quite complex people . . . it’s difficult then to make referrals on to other places until I guess things settle for them, or they never settle . . . So I could see it
(physiotherapy) would be more appropriate for clients that are exiting the programme, a higher level of function, but not the clients that need that kind of service the most (M8)
And even if we liaise with GPs . . . it has to be with the individual’s consent . . . A lot of our clients struggle with motivation (M9)
We’ve got about a 30% DNA [did not attend] rate for appointments here . . . it’s difficult enough to get the client to come for an appointment regarding the medication never
mind another appointment for something else (M16)

Theme 4: Enablers to referrals to physiotherapy services

Subtheme 4.1: Factors involving healthcare service providers

We have very little awareness . . . that would be for the physiotherapist or physiotherapy association . . . to actually start creating an awareness campaign so that it would
raise . . . our perspective of what they have to offer (M15)
Very important that there is this person that understands a lot about clients that they’re working with, they don’t need to address any of that, but at least they could, you know,
be comfortable with working with people . . . (M1)
I’m wondering whether, from a physiotherapy perspective, if engaging the universities a bit more in coming in to do particular things, because we don’t see any physiotherapy
students . . . (M19)
I’d actually say we should have everything under the one roof, it’s a one stop shop (M20)
Clear processes for referring people in to outpatient physiotherapy, as well, maybe having a list of who are the physiotherapists in the area, who would be interested engaging
with our client group . . . (M21)
Subtheme 4.2: Factors related to the individual with mental illness
Money, transport, their understanding why they’ve been referred to . . . what they will benefit from it . . . (M19)

mental health. They expressed the need for physiotherapists to be
equipped with adequate knowledge and skills about mental health
conditions and their treatment approaches, and identified the need
for practical experience in a mental health setting as part of
physiotherapy education.
Theme 2: Structural barriers influencing referral process and uptake of
services
Structural barriers were categorised into three subthemes.
Subtheme 2.1: Limited funding influencing capacity to address physical
health problems
All mental health professionals were unequivocal in identifying
limited funding as a major structural barrier influencing their
ability to manage the physical health of people with SPMI. This
barrier has led to an increased reliance on external providers, such
as non-governmental organisations, to assume responsibilities for
physical health needs of these individuals.
Some mental health professionals were unaware of inclusion of
physiotherapy services in the Chronic Disease Management plan
aimed at assisting people living with chronic conditions with their
complex health needs. This initiative allows the provision of five
allied health sessions per year as part of an individual’s general
practitioner (GP) care plan. Mental health professionals who were
aware of physiotherapy’s inclusion raised questions regarding the
adequacy of five sessions to manage the complex needs of these
individuals.
Subtheme 2.2: Capacity and suitability of external services for physical
health
GPs were seen to be the ‘gatekeepers’ of physical healthcare for
people with SPMI. In general, mental health professionals relied on
172 Lee et al: Physiotherapy for people with mental illness

Table 3
Thematic interview responses of people with severe and persistent mental illness.

Theme 1: Limited awareness and understanding of the role and scope of practice of physiotherapy

They work on your joints and any particular problems that you might have with your joints and muscles (S22)
They (physiotherapists) relax your muscles and make you do bendy exercises (S27)
I don’t know what a physiotherapist is actually (S15)

Theme 2: Barriers to accessing physiotherapy

Subtheme 2.1: Transport

Getting there and getting home and all that . . . Mainly transport. I don’t like catching trains and buses (S4)
Subtheme 2.2: Cost of service
Payment is a very, very big issue. I don’t . . . I think . . . I don’t know about anybody else, but I’m on disability support pension (S11)
I can’t afford it, can’t afford physio. That’s probably one of the only reasons I don’t see one, it is the money side of things (S35)
You know they give out 10 sessions throughout the year and then after that you’re expected to pay each time. And okay, there’s concession cards and things like that, but in saying
that, not everybody’s got the money to go to physio (S29)
Subtheme 2.3: Limited knowledge of service
I actually don’t know what a physiotherapist can do for me (S3)
Subtheme 2.4: Intrinsic factors
Obviously the depression or whatever, you know there’s a lot of ‘I can’t be bothered’ and it just can come out of nowhere or that you just want to stay in bed and all that behaviour
and stuff with the mental illnesses (S12)
When I have it now they don’t do it the same anymore; it’s not as good as what it used to be . . . You’d get the physio and do exercises in the physio and then a massage after;
after I got sore from exercise, and that helped a lot. And I told the woman there, I said, ‘If I do the exercise. If I don’t get a massage after I won’t do it.’ (S32)
I don’t know if that’s true or not but I imagine they don’t take it holistically to find the real reason for the pain (S11)
I think another thing with physio is it’s kind of like with all other problems that we’re facing it’s kind of like not the most essential thing in the world. And when it comes to having
like smokes or physio, it’d be like, you know, hands-down smokes. Or you know, even getting to a physio because it’s kind of like - I don’t drive, so yeah (S12)

Theme 3: Enablers to physiotherapy access

Subtheme 3.1: Referrals from healthcare professional

Through the staff and from the GP [would make it easier to access a physiotherapist] (S15)
Subtheme 3.2: Education regarding physiotherapy
It would be great if there was some information made available [about the role and benefits of physiotherapy] (S3)
Subtheme 3.3: Social support
They [mental health team] are very supportive . . . they give me a little bit of a push to go and look for the help that I need (S25)
I find that the greatest support I had was from my family and friends (S30)
Subtheme 3.4: Reduced cost of service access
Maybe you can find a way where NDIS could subsidise some of the sessions. As opposed to going to your doctor maybe NDIS could give you if it’s through mental health and
getting physically better maybe they can subsidise some of the sessions for you. So instead of having five sessions you may have 15 because you only get so many a year (S30)

GPs to manage the physical health of people with SPMI and
assumed that it was the responsibility of the GPs to organise
services and relevant referrals pertaining to physical health.
However, mental health professionals also raised questions
regarding the capacity of GPs to adequately manage both the
physical and mental health of patients, given time constraints
among other reasons. In addition, participants reported uncer-
tainty regarding the outcome, due to poor communication
between services.
Subtheme 2.3: Receptivity of external services
Lastly, referral processes of mental health professionals were
influenced by the willingness of external services to accept people
with mental illnesses. Participants reported that uncertainty over
the receptivity of various physiotherapy services to people with
mental illnesses limited their ability to make appropriate referrals.
Theme 3: Patient-specific barriers influencing the referral process
In addition to structural barriers, factors specific to the
individual patient were mentioned. These barriers included cost
of services, transport, severity of mental illness and motivation.
Subtheme 3.1: High associated cost
Participants noted that the most decisive factor influencing
referral processes were the costs involved for the person with
mental illness.
Subtheme 3.2: Transport
Location and availability of transport to the service were also
identified as influential.
Subtheme 3.3: Factors associated with the mental illness
Participants also considered the individual’s mental health and
suitability for a physical health program. They acknowledged that
despite their best intentions when organising services, choice of
care and service uptake ultimately resided with the patient.
Mental health professionals spoke of the lack of motivation
experienced by people with SPMI, which might be a symptom of
their mental illness, a medication side effect, or a consequence of
their physical co-morbidities. This issue had negative implications
for attendance at appointments with all healthcare services.
Theme 4: Enablers to referrals to physiotherapy services
Enablers to referrals were closely related to the barriers
mentioned above.
Subtheme 4.1: Factors involving healthcare service providers
Mental health professionals expressed the need for education
about the role of physiotherapy in mental health. Increased
awareness and knowledge would be helpful in identifying
individuals who may be suitable for physiotherapy. Likewise,
the mental health professionals identified the need for phy-
siotherapists to be equipped with adequate skills and knowledge in
mental health as another factor promoting referrals to physiother-
apy.
Mental health professionals spoke of ways of reducing their
uncertainty regarding their ability to refer patients directly to
physiotherapy. Clear and simple referral pathways were identified
to be enablers for participants. Lastly, integration of physiotherapy
into the mental health service was a proposed enabler to facilitate
access to services by people with SPMI as part of primary mental
healthcare.
Subtheme 4.2: Factors related to the individual with mental illness
Mental health professionals cited factors specific to the
individual patient that might facilitate referrals to physiotherapy.
These included education regarding physiotherapy and informa-
tion regarding affordability of services. Education regarding the
benefits of physiotherapy was seen to enable the individual to
make informed decisions. Heavily subsidised services and provi-
sion of transport were also identified as key enablers.
 Research
People with SPMI
Largely consistent with the findings from mental health
professionals, responses from participants with SPMI were
classified into three main themes. Table 3 describes their themes
and provides supporting quotes.
Theme 1: Limited awareness and understanding regarding the role and
scope of practice of physiotherapy
The participants with SPMI expressed limited awareness about
the role of physiotherapy. Most were able to identify the role of
physiotherapy, particularly in managing musculoskeletal pro-
blems, but were limited in their understanding of physiotherapy
for their general physical or mental health.
Theme 2: Barriers to accessing physiotherapy
In exploring barriers to physiotherapy access, the participants
with SPMI identified factors similar to those highlighted by mental
health professionals.
Subtheme 2.1: Transport
Location of and lack of transport to the physiotherapy service
were seen to be major barriers to accessing physiotherapy. The
issue of transport was especially salient for those people who
preferred not to use public transport services.
Subtheme 2.2: Cost of service
The participants with SPMI were unanimous in identifying cost
as one of the greatest barriers to physiotherapy access. Despite the
provision of subsidised services, those participants with previous
physiotherapy experiences raised concerns regarding the effec-
tiveness of the limited number of sessions covered.
Subtheme 2.3: Limited knowledge of service
Limited awareness and understanding of the role of physio-
therapy further act as a barrier to physiotherapy access for people
with SPMI. Participants expressed that they were less likely to
access physiotherapy services if they were uncertain about the role
and benefits of physiotherapy.
Subtheme 2.4: Intrinsic factors
Similar to the mental health professionals, the participants with
SPMI expressed that healthcare access was fundamentally client
driven. Limited motivation was highlighted as a key factor
influencing access to healthcare services. This factor was often
attributed to be a symptom of the individual’s mental illness that
had effects on their access to healthcare services and, consequent-
ly, on their physical health.
The participants with SPMI also spoke of their perception
of the effectiveness of physiotherapy as a potential barrier to
service access. They reported being less likely to access
physiotherapy services if previous experiences were perceived
to be ineffective. Likewise, participants with no previous
experiences with physiotherapy expressed reduced likelihood
of accessing services if they envisaged physiotherapy to be
ineffective.
Lastly, many of the participants with SPMI reported physical
health and physiotherapy to be of a low priority compared to their
mental health and other needs. Consequently, they were less likely
to access such services because other issues such as time, being
able to afford cigarettes and their mental health take precedence
over physical health.
Theme 3: Enablers to physiotherapy access
The participants with SPMI spoke of four main enablers to
accessing physiotherapy services.
Subtheme 3.1: Referrals from healthcare professionals
Participants said that they would be more likely to access
physiotherapy services if they were referred by a mental health
professional or their GP.
Subtheme 3.2: Education regarding physiotherapy
173
There was unanimous agreement that education regarding the
role of physiotherapy in benefiting physical health would
encourage people with SPMI to access physiotherapy services.
Subtheme 3.3: Social support
The participants with SPMI also identified encouragement from
mental health professionals or family members as an enabler in
encouraging access of physiotherapy service.
Subtheme 3.4: Reduced cost of service access
The majority of participants thought that reducing the cost of
physiotherapy would facilitate access. Provision of more sub-
sidised physiotherapy sessions was also seen as a possible solution
to the cost barrier, in addition to addressing issues regarding
adequacy and effectiveness of limited subsidised sessions.
Discussion
It is believed that this study is the first to examine factors
influencing physiotherapy involvement in mental healthcare from
the perspectives of mental health professionals and people with
SPMI. Discussions at focus groups and interviews supported the
existing impression that physiotherapists are under-utilised in
providing care for people with SPMI. A number of reasons for this
situation emerged.
Both groups of participants reported a general lack of
understanding about physiotherapy and its relevance in mental
healthcare. This is consistent with recent literature in mental
healthcare from other countries, which has reported a lack of
consideration for physiotherapy in managing physical co-morbid-
ities and in leading physical activity rehabilitation programs for
people with mental health conditions, despite the prominence of
physiotherapists in this role in other areas of healthcare.11,14,20 The
lack of understanding about physiotherapy not only serves as a
barrier to service access, but also highlights the potential for
greater advocacy and physiotherapy involvement in mental health.
Mental health professionals identified structural barriers, such
as limited funding and lack of awareness of suitable services, along
with uncertainty regarding their authority to refer to physiothera-
py, as factors that limit referrals to physiotherapy. Moreover, they
questioned the knowledge and skills of physiotherapists to manage
complex presentations of people with SPMI. This is also consistent
with a lack of available information and visibility of physiotherapy
in mental health.
Limited funding in mental healthcare has led to an increased
reliance on non-governmental organisations and GPs to address
physical health issues of people with SPMI, and an emerging
dichotomy between physical and mental health services.4,10 This
divide, combined with poor communication between service
providers, has led to assumptions that referrals to appropriate
services for physical healthcare for people with SPMI are the
responsibilities of the treating GPs. However, it is uncertain
whether GPs are aware of the role and relevance of physiotherapy
for people with SPMI. The poor understanding about the role of
physiotherapy by people with SPMI would suggest not. This
discontinuity in care and dichotomy of physical and mental health
needs is likely to hamper improvement in the physical health of
these individuals.21
Enablers to physiotherapy access closely reflected the identified
barriers. Integration of services to enable access to physical health
interventions as part of primary mental healthcare for people with
SPMI has been suggested both in Australia and internationally20,22
and would help to overcome the cost barrier. It would also help to
expose mental health professionals and patients alike to physio-
therapy. Improved understanding about the role and benefits of
physiotherapy has been recommended by the participants and
previously as an essential step towards integrating physiotherapy
within mental health services and, consequently, enabling greater
access.23
174 Lee et al: Physiotherapy for people with mental illness
Education and clinical experience in mental health has been
advocated to ensure that graduating physiotherapists are equipped
with the necessary knowledge and skills to manage patients with
co-morbid mental illness.11,23,24 This experience is relevant to all
fields of physiotherapy, given the prevalence of mental illness.11,14,25
The results of this study also emphasise the importance of
social support in encouraging engagement with healthcare
interventions among people with SPMI. Motivational impairments
are characteristic among these individuals and negatively influ-
ence engagement with healthcare services.26 This parallels
findings documenting social support as a key extrinsic motivator
in encouraging adherence to physical activity and smoking
cessation interventions.27,28
This study had several limitations. The generalisability of the
results is limited by all participants having been recruited from
the Perth metropolitan area. Second, individual interviews were
conducted to accommodate schedules of a few participants. Unlike
focus groups, exchange of ideas would not have been possible in
individual interviews. However, information reported in individual
interviews paralleled those discussed in focus groups, and data
saturation was achieved. Individual interviews could, however,
also be considered as a strength of the study, as they provide
participants more privacy to comment on issues they may have
been reluctant to explore in a group setting.
There is potential for physiotherapists to be leaders in the
management of physical co-morbidities and physical activity
interventions as members of a multidisciplinary mental health
team. Of importance to physiotherapists is the limited under-
standing of the role and relevance of the profession in mental
healthcare, and it being perceived as ineffective and lacking in
mental health education by both groups of participants in this
study. Underpinning these factors is the reported absence of strong
physiotherapy presence and advocacy within the mental health
community.
What is already known on this topic: People with severe
and persistent mental illness (eg, schizophrenia, schizoaffec-
tive disorders, bipolar disorder and major depression) typically
have low physical activity levels and poor physical health.
Personalised physical activity programs are beneficial in this
population.
What this study adds: There is a need for greater under-
standing about how physiotherapy can contribute to physical
health in people with mental illness. Physiotherapy has limited
presence and advocacy within the multidisciplinary mental
healthcare team. Physiotherapists need to be well equipped
with skills and knowledge in mental health to facilitate greater
involvement.
Footnotes: a SPSS 23, IBM SPSS Inc, Chicago, USA.
Ethics approval: Ethics approval for this study was obtained
from North Metropolitan Health Service-Mental Health (NMHS-
MH) Human Research Ethics Committee (reference number
09_2015) and the Human Research Ethics Committee at Curtin
University (reference number HR216/2015). All participants gave
written informed consent before data collection began.
Competing interests: Nil.
Sources of support: This study was funded by the School of
Physiotherapy and Exercise Science at Curtin University.
Acknowledgements: The authors would like to acknowledge Ms
Vivian Chiu for her guidance in focus groups.
Provenance: Not invited. Peer reviewed.
Correspondence: Dr Robyn Fary, School of Physiotherapy
and Exercise Science, Curtin University, Perth, Australia. Email:
R.Fary@curtin.edu.au
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