By Cindy McGlynn
Spring 2004, Vol 7 No 3
For Steve McNall and others in his hockey group, Tuesday is the best night of the week. It’s when some 18 players – mostly men – meet at their rink in Owen Sound, Ontario, for a pick-up hockey game. They get some exercise, work on their skills and maybe go for dinner afterwards. After nine years of playing, McNall’s own skills have advanced so much that he also plays with an all-men’s league and even has a job supervising the Tuesday night games and other recreational activities. These hockey matches are like thousands across Canada – with one difference: each player has a serious mental illness.
McNall himself was an accomplished high school athlete not long before being diagnosed with schizophrenia. Since then, a 20-year battle with the illness has included bouts of homelessness and substance use problems. Today, McNall is doing well on his medication. He is married and works part-time as a recreation co-ordinator.
He says he owes a large part of his recovery to his background as an athlete and his weekly hockey games. “I don’t have as many symptoms now, and I attribute my well-being to the workouts and the teamwork,” says McNall. “Group hockey has been so good, it helped me recover to the point that I was even eligible for my job.”
Stories like McNall’s are inspiring, but all-too rare. Exercise is healthy for anyone, but for people with severe mental illness, research suggests that physical activity may be very important to recovery. In addition to cardiovascular benefits, which are desperately needed by a population plagued with poor health and a high morbidity rate, exercise increases self-esteem, helps build social skills and reduces isolation. And when done properly, it has no negative side-effects. A 1999 study published in the Psychiatric Rehabilitation Journal found lowered feelings of depression and improved self-esteem, body consciousness and activities of daily living among participants with bipolar disorder, depression, schizophrenia and borderline personality disorder who exercised three days a week over a period of 15 to 20 weeks.
Exercise may even reduce psychotic symptoms such as auditory hallucinations. A 1999 study published in the Journal of Sport and Exercise Psychology found that clients with schizophrenia reported hearing fewer voices on the days they participated in a voluntary exercise program. Participants also reported sleeping better and feeling better about themselves and their bodies. The benefits seemed to last up to three hours after each exercise session.
Despite these positive findings, little has been done to promote physical activity among people with mental health issues. “There are enormous benefits to exercise programs like these,” says Owen Sound social worker and case manager, Mike Schwan. He should know: he’s been facilitating the weekly recreational hockey league for Steve McNall and his teammates for most of the 14 years it has been running. Everyone is welcome at these games, no matter what their skill level. “Players always say how energized they feel after a game,” says Schwan. “The fitness benefits help them cope with symptoms of illness like lack of motivation or lack of energy. The other thing is the teamwork – passing to other players or setting up a goal or scoring gives teammates a feeling of involvement in something greater than themselves. Players also feel a sense of normalcy. Hockey is Canada’s national sport and people feel like they are participating in something that’s valuable in Canada.”
Facilitating the games started as a voluntary pursuit for Schwan, who went after the workday was over. His employer now recognizes the value of the games, and Tuesday night games are now part of Schwan’s job description. But this sort of recognition of the value of physical activity is not the case in many places. Guy Faulkner, an assistant professor in the University of Toronto’s Faculty of Physical Education, says there are still many barriers to implementing exercise as routine therapy. Systemic and attitudinal barriers persist in the medical community, where the focus remains treating illness rather than promoting wellness. The fact that it is unclear how much to prescribe and even how exercise works to ease psychiatric symptoms and improve well-being make physicians wary of considering it as a viable treatment. “Those are very important questions, and the research still needs to be done,” says Dori Hutchinson, director of the Center for Psychiatric Rehabilitation at Boston University. “But in some ways, it’s no different than the general population. We are approaching exercise for people with mental illness like it’s different. People without mental illness reap physiological and mental benefits from exercise and so do people with mental illness.”
The answer to the question of how much physical activity to prescribe is individual evaluation, says Paul Martin-Demers, a recreation therapist who works with up to 200 clients a week at the Centre for Addiction and Mental Health in Toronto. “The first thing that needs to be understood is the needs of the client,” says Martin-Demers. “If someone who is severely mentally ill comes to me and says, ‘I just want to participate in basketball,’ I need to remember they may not have played in 20 years. They’re on medication, which perhaps has promoted weight gain.” Martin-Demers’ clients go through a series of evaluations before beginning a program. Their medications are researched to ensure there are no contraindications, and they have an ECG to check cardiac health.
Boston University’s Center for Psychiatric Rehabilitation takes the same approach. “We’ve learned to provide a wide range of wellness options because people are at different points of readiness to change their lifestyle,” says Hutchinson. “It might be something as simple as taking a healthy lifestyles class where they learn what a healthy lifestyle looks like. We also offer courses in tai chi and yoga. It’s important to remember that not everyone can hop on the treadmill for 20 minutes.”
Some practitioners are daunted by how to motivate clients who have low self-esteem, significant weight gain and low energy as a side-effect of medication or the illness itself. But it may not be much different than motivating anyone to exercise. “Like everyone, clients feel strapped for time, or feel overwhelmed by unattainable goals like losing significant amounts of weight,” says Martin-Demers. His approach to motivation is three-fold: goal setting, progressive exercise and, perhaps most importantly, one-on-one support. For example, he would encourage a goal of walking several times per week instead of losing 30 pounds. The sessions would advance progressively, starting off gently and building intensity as the individual gains strength and endurance. Martin-Demers is with the client every step of the way, literally. “I give them the activity and participate in the activity. Each time they run, I’m there.”
Hutchinson agrees that personal support is crucial. “When you provide individual support, the results are much better,” she says. “That can be anything from calling people up and encouraging them to come to exercise class, to exercising with people, to charting their progress over time so they can visually see that they are making progress.” The results Martin-Demers sees are remarkable. One woman went from having never run, to completing a 10-kilometre race four months later. “We worked progressively, starting with a walking program for 30 minutes, then a run/walk program and then a running program. Before we knew it, she ran a 10k.”
For people with mental illness, the body often becomes the enemy. It is something to be controlled, medicated and fought against. One of the biggest benefits of physical fitness may be reconnecting with their bodies as a source of strength, rather than a source of illness and pain. “We tell our clients that they have a body that has value that we hold in high esteem,” says Hutchinson. “We help people begin to make changes for themselves. And we spend a lot of time telling people they have a right to a healthy body, just like anyone else.”
For more information about the Owen Sound hockey group, contact Mike Schwan at Community Connections, at 519 371-2390.
The best-documented mental health benefits of exercise are in the area of treating depression. In fact, research out of Duke University has found that exercise is better than medication as a treatment for people with depression. In a 1999 study published in the Archives of Internal Medicine, James Blumenthal and colleagues worked with 156 older people with major depression. The participants were divided into groups: one group attended a group exercise program, another group attended the exercise program and took the anti-depressant Zoloft and a third group took the anti-depressant only. Participants who exercised only showed greater improvement than the other two groups. “Our findings show that a moderate exercise program is an effective treatment for patients with a major depression,” writes Blumenthal. A follow-up study found that those treated with the exercise-only model were less likely to relapse into depression than those who exercised and took Zoloft. Exercise also seems to help reduce anxiety. A 1994 analysis of studies from 1960 and 1991, presented by Daniel Landers and Steven Petruzzello at the second International Conference on Physical Activity, Fitness, and Health, found that 81 per cent of the studies concluded that physical activity and fitness were related to anxiety reduction following exercise.
Research evaluating the benefits of physical activity in treating mental illness is impressive and hopeful. But many systemic and individual barriers need to be overcome before advocates may see exercise surface as a routine part of mental health treatment.
The very root of the problem, according to Dori Hutchinson at Boston University’s Center for Psychiatric Rehabilitation, may be the separation between mental and physical health treatment. “What we’ve done as a field is to work so hard to treat illness that, without meaning to, we have disconnected mind/body/spirit. We are not approaching wellness in a holistic way. Certainly, the mental health process does not work to promote wellness – it works to treat illness.”
Guy Faulkner, at the University of Toronto’s Faculty of Physical Health and Education, says physicians who wish to prescribe exercise are met with a systemic lack of resources and trained professionals. “The structures are not in place,” he says. “A clinician can’t say, ‘I will refer this client to a certain facility,’ knowing that the person running that facility is qualified and has the expertise to work with people with mental health problems.” Faulkner and Hutchinson agree that people with mental illness are often financially unstable, and in the absence of a funded facility, it is unlikely they will pay for a gym or facility membership themselves.
It is also hard to pinpoint exactly why exercise works to ease symptoms of mental illness. Therefore, research-oriented practitioners overlook exercise in favour of more readily measured treatments. “To put it simply, exercise perhaps is too simple,” says Faulkner. “Is it even a mental health treatment? We can’t specify dosage and I don’t think we ever will. We don’t know why it works. But if you look at anti-psychotic medications, we don’t know how they work either; yet they are routinely prescribed. We need more research and an attitude shift.”
A 2001 study led by Faulkner and published in the Journal of Sports Sciences stresses that more research is needed to overcome these individual and systemic barriers. “Until it is easier for mental health professionals to access opportunities for their clients, the use of exercise as a therapeutic medium will rely on serendipity,” write the authors.
Since 1983, a Toronto-based program called Boundless Adventures has been using exercise and outdoor adventure to build life and social skills for people with mental illness, acquired brain injuries, developmental disabilities and other special needs. Working in partnership with Ontario-based community agencies, the program aims to prevent crime, promote alternatives to substance use and strengthen the bonds of families and communities ravaged by poverty, violence and mental illness.
The activities are centred on an Ottawa Valley wilderness facility and include white-water rafting, climbing, ropes courses, eco-challenges and team building workshops. Fees are subsidized by the Ontario Ministry of Health and Long Term Care for participating groups of up to 12 people from recognized mental health and long-term care agencies.
Participants report leaving the programs with increased self-esteem, hope and optimism. “My confidence all of a sudden had completely turned around,” writes one participant in the company’s annual report. "I started to think that I was able to do things I only dreamed about.”