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

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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
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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

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• 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

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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)
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Psychological equivalent??!!
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Physical activity choices???
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The health consequences of avoiding physical
activity???
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• If
• physical inactivity is a factor in the
  development of mental illness
• Thenphysical 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

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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
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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
• Doesnt reflect context of all practitioners
  (e.g. community/out patient based or non
  clinical) but transferable issues are apparent

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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
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• 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
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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 didnt 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
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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
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• 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
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• 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
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• 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

Clear links to evidence for the use of exercise
biopsychsocial?
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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

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Preaching to the converted!

• Those who attend already have experience and
  knowledge of the area
• This area isnt 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?

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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

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References (continued)

• Hausenblas H, Brewer B and Vann Raalte (2004)
  Self Presentation and Exercise. Journal of
  Applied Sport Psychology. 1613-18
• 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 GPs)
• 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
  477514
• 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.