The use of exercise in mental health: using case studies to reflect on practice

1. The use of exercise in mental health: using case studies to reflect on practice Thursday, 22nd May 2008 Mr. Andy Buckton, MSc Res, BA Hons York St John University, Faculty of Health and Life Sciences

2. Part of an ongoing programme of CPD study days for Health Professionals • The evidence for the use of exercise within treatment/management • A psychological perspective on the relationship between exercise and psychological well-being • Reflection on practice • Acute affective responses to exercise • Associated areas within exercise psychology

3. The study and teaching of this area connects the physical and mental health perspectives Discussing the role of physical activity and exercise, Biddle and Mutrie (2008: 206) observe that… ‘Maybe the mental health literature is suffering from a dualist tendency to treat the mind (mental health) and body (physical health) as separate issues, thereby failing to recognise mental outcomes of a physical treatment such as exercise (Beesley and Mutrie 1997; Faulkner and Biddle 2001a). Rejeski and Thompson are more optimistic in suggesting that we are moving away from dualism: ‘The mind-body distinction has slowly, but noticeably yielded to the concept of biopsychosocial interactions – the position that the body, the mind, and the social context of human existence are reciprocally interdependent on one another’ (Rejeski and Thompson 1993: 7). Physical activity / inactivity is clearly related to both physical and psychological and social consequences

4. CVD Metabolic Disorders Musculoskeletal Physical inactivity Pulmonary Disease Cancers Mental Illness e.g. mental health problems increasing risk of cardiovascular disease (Shimbo et al. 2005)

5. Psychological equivalent??!!

6. Physical activity choices???

7. The health consequences of avoiding physical activity???

8. If… physical inactivity is a factor in the development of mental illness Then…physical activity should be a factor in the care and treatment of mental illness Advocating an integrated approach with existing treatments – implications for professional health education and training in exercise and physical activity

9. A potential perspective on the relationship… • Low Body Image • High Social Physique Anxiety • Low Self Worth • Secondary mental health problems • Restriction of Physical Activity • Social Isolation (& reinforcement) • Obesity and physiological conditions – physical disability • Unhealthy behaviours (e.g. Binge/Comfort Eating) Mental Illness

10. Using a case study approach • Examples of how the introduction of exercise has been beneficial for patients at a medium secure psychiatric hospital • Enabling: • Reflection on own practice and experiences • Share experiences • Develop discussion • Alternate approaches • Links to theory and evidence • Doesn’t reflect context of all practitioners (e.g. community/out patient based or non clinical) but transferable issues are apparent

11. Example Case Study: 21 year old female Background: • Diagnosis- Personality Disorder (cognition (perception and interpretation of self, others and events) interpersonal functioning • History of drug and alcohol abuse • Episodes of paranoia and psychosis • History of eating disorders • Suffered with depression & low self esteem • Conscious of extensive scars on her body from self injury • Scared of other patients especially males • Reported past interests – swimming, music & art Benefit from increased physical activity and appropriate exercise Self presentation, social physique anxiety, self esteem issues

12. Initial Approach: • Allocated 2 individual sessions per week • Focus on depression and low self esteem • Gym Induction: Offered individual programme including advice on diet and exercise – patient declined • Wanted to power walk on the treadmill for 20 minutes per session • Wanted to be left alone during the workout (no eye contact, dark glasses), listened to her own music • Exercise leader worked out in the gym in order to monitor patient • Cup of tea with patient following sessions to make conversation and get to know her. • Gradually opened up over 4 weeks, allowing more interaction and developments in exercise programme Attitude: existing beliefs and value of exercise Evidence of motivation to exercise Development in social interaction and self-efficacy

13. An adherer ! Progression (weeks 4-8) • Attending 3 times per week • Group gym sessions working to an individual programme (controlled weight loss/toning programme) • Combating weight gain (medication effects) – expressed that she didn’t like taking medication due to the weight gain • Individual swimming sessions wearing shorts and t-shirt (still conscious of scars) • Group aerobic/circuit sessions • Badminton Progression (week 8+) • Group swimming sessions (female only) • Jogging (out of hospital grounds) • Working with dietician Self presentation, issues, addressing social physique anxiety Variation, choice of modes, developing competence (self-efficacy) Autonomy, distraction, liberty, progress

14. Developments in fitness, continued control of weight gain etc. Progression (week 8+) • Minimum of 4 sessions per week (good adherence) • Combination of group swimming sessions (female only), jogging (out of hospital grounds), gym sessions • Working with dietician Exercise leaders observations (12 weeks) • Improved self esteem • Improvement in confidence during group activities • Requesting exercise sessions when low in mood to lift mood ‘feel-better’ effect – changes in physical self worth and self esteem (mastering new tasks, personal control etc.) Self awareness of acute affective response or sense of mastery

15. Community Based Physical Activity Proposal • To offer the patient a wider variety of activities to maintain her motivation levels and commitment to her programme. • The patients previous experience in the community involved drugs and alcohol. A community based leisure programme will give her the opportunity to become socially involved in more productive activities. • To enable the patient to develop confidence through developing skills in a community setting • Approved by clinical team Social skills and engagement Self confidence in a community setting

16. Progression (aprox 10 month period) • Accessing a range of community leisure facilities with the instructor. • Open swimming sessions • Improved social skills • Jogging in the community with instructor Progression – pre discharge • Accessed community leisure services independently • Jogging and walking independently • Recognising the benefits of exercise to her own mental health Facilitating independence, accessible distraction from environment Developed strength of belief in the value of regular exercise and physical activity

17. Clear links to evidence for the use of exercise ‘biopsychsocial’? Feedback from patient prior to discharge to an open hospital Regular exercise at the gym helps me in a number of ways:- • Relieves anxiety,agitation • Anger control • Lifts mood • Makes me feel good about myself because • I look okay and healthy • Stops weight gain from a sedentary lifestyle • Keeps me strong • Gives me purpose. If I have no structure in my day/week it gives me regular purpose and structure

18. Observations of using this approach in my teaching • Effective in generating debate through reflection on experience and observations • Challenges to approaches used • Provides a context to theory and evidence • Highlights disciplinary perspectives • Develops educators knowledge of current issues and uses of exercise interventions

19. ‘Preaching to the converted’! • Those who attend already have experience and knowledge of the area • This area isn’t reaching many who may benefit (implications for professional undergraduate and post graduate qualifications) Questions • How can we spread a wider net? • Value of multi-disciplinary education? • How can this physical domain be utilised more effectively within mental health education and practice?

20. References Bartholomew JB, Morrison D and Ciccolo JT (2005) Effects of acute exercise on mood and well-being in patients with major depressive disorder. Medicine & Science in Sports & Exercise. 37, no12, pp2032-2037 Biddle S. J. H., Fox K.R. and Boutcher S.H. (Eds) (2000) Physical Activity and Psychological Well Being London, Routledge Biddle SJ and Mutrie N (2008) Psychology of Physical Activity: Determinants, well-being and interventions (2nd Ed), London, Routledge Carless D and Faulkner G (2003) Chapter 4 - Physical activity and Mental Health, in McKenna & Riddoch (2003) Perspectives on Health and Exercise, Palgrave Macmillan Carless D and Sparkes AC (2008) The physical activity experiences of men with serious mental illness: three short stories. Psychology of Sport and Exercise. 9, pp191-210 Department of Health (2004) At least five a week: Evidence on the impact of physical activity and its relationship to health, A report from the Chief Medical Officer. DOH – (section 5.5, pp58-63) Furnham, A (2002) Body image dissatisfaction: gender differences in eating attitudes, self-esteem, and reasons for exercise, The journal of psychology, 136, no. 6, pp581-596 Grant T. (Ed)2000, Physical Activity & Mental Health: Nationals Consensus Statements and Guidelines for Practice, Somerset Health Authority

21. References (continued) Hausenblas H, Brewer B and Vann Raalte (2004) Self Presentation and Exercise. Journal of Applied Sport Psychology. 16:13-18 Leary M (1992) Self presentational processes in exercise and sport. Journal of Sport and Exercise Psychology. 14, 339-351. Mental Health Foundation (2005) Up and Running? Exercise therapy and the treatment of mild to moderate depression in primary care. London: MHF - (Executive Summary and Advice Leaflet for GP’s) National Clinical Practice Guideline Number 23: Depression: Management of depression in primary and secondary care – (Other treatments: Exercise pp99-105) National Clinical Practice Guideline Number 22: Anxiety – (Exercise and Panic disorder pp97-98 and Exercise and Generalised Anxiety Disorder p142) Reed J. and Ones D. S. (2006) The effect of acute aerobic exercise on positive activated affect: A meta-analysis. Psychology of Sport and Exercise 7 477–514 Shimbo, D Chaplin, W. , Crossman, D., Haas, D. and Davidson, K.W. (2005) Role of depression and inflammation in incident coronary heart disease events. American Journal of Cardiology, 96(7), 1016-21.