Description #

Meet Gary.

Gary is a real life person who used running to help him manage his symptoms of depression. He shared his story of exercise and mental health as part of the #littlethings campaign through yourmentalhealth.ie. You can listen to or read about Gary’s story at: http://www.yourmentalhealth.ie/get-involved/real-life-stories/little-things-stories/gary-s-story.html

What do I need to know? #

Almost everyone experiences symptoms of stress and anxiety at some point. For many, it’s just a part of their daily lives (e.g., feeling down, difficulty sleeping, increased heart rate, loss of energy)! These symptoms can actually play a role in helping us manage the demands of various life events. Think about how you felt when you started your last job, if you got married or divorced or if you have managed a home renovation project.  Here’s the thing, problems only arise when these symptoms become too difficult to manage. For example, if they occur too often and too intensely, you may be left feeling overwhelmed, especially if it interferes with your daily life (basically you can’t get rid of these feelings!). This is when it might be time to seek out some support from either a medical professional or one of the other community support networks.

For people who are diagnosed with mental health issues, exercise can be a great way to manage their symptoms. If they don’t have any other physical condition, you can proceed with a regular fitness assessment and exercise prescription. The information below will help you to understand a little more about the different kinds of mental health issues individuals may experience, along with some suggested resources for more information or if people are looking for further support.

DID YOU KNOW?

Many people with other disability diagnoses or impairments are also affected by mental health difficulties. For example, approximately 80% of people on the autism spectrum also experience mental health difficulties such as anxiety and depression (Autistica, 2017).

You may want to consider encouraging professionals in your organization to complete Mental Health First Aid training (this can be a great complement to Standard First Aid Training). It’s available in 23 countries, including Ireland (http://www.mhfaireland.ie ), Canada (http://www.mentalhealthfirstaid.ca/en ), and the USA (https://www.mentalhealthfirstaid.org/).

It can feel scary and stressful if someone comes to you and says they are having mental health difficulties. Here are a few things you can do right away:

• Sometimes people just need to talk.
• Ask questions.
• Don’t judge.
• If talking is not enough, be familiar with the support services that are available in your community. Suggest they speak with someone else and provide a phone number they can call.
• Check out http://www.yourmentalhealth.ie/ for more tips and other great information.

The following overview describes some of the common mental health issues you may encounter. Please be aware that many people will not disclose that they are affected by these issues. Your job is to be supportive as much as possible and respect an individual’s decision whether or not to disclose a diagnosis.

Anxiety

Anxiety is a common experience (something everyone faces at some point in their life). For some people, it is passing emotion, often situated within specific circumstances (remember when we talked about what it’s like to get married or start a new job?), however, for others, it can be an ongoing emotion that ends up disrupting and getting in the way of regular life. Managing anxiety can feel both overwhelming and exhausting.

Stress

Sometimes stress can be positive (it may even be helpful as you prepare to tackle the challenges that life can bring!), however, when stress levels become too high, you may not feel ready to take on these demands. You might change the way you act or view the world, and too much stress can effect your energy levels. Everyone experiences stressful situations differently, so there is no one size fits all approach.

Eating disorders

These are complex behaviours that may involve unhealthy eating patterns (e.g., restricted eating, purging, or excessive exercising).

Depression/ feeling down

Depression is about more than feeling down once in awhile or having a bad day. It doesn’t go away over night. Someone may be experiencing depression if the symptoms of feeling down are interfering with everyday life for two weeks or more.

Self-harm

Some people use self-harming as a way to deal with emotional distress. If someone shares this kind of behaviour with you, recommend support to help them find coping strategies to manage the associated emotional pain.

Panic attacks

Panic attacks are short lived feelings of intense fear or high levels of anxiety. Although they may not last long, panic attacks can be severe and quite frightening. Panic attacks are experienced differently by different people (and therefore the same strategy to help may not work for everyone).

Suicidal thoughts

It’s important that you are aware of the support services that are available in case someone shares that they are struggling with thoughts of suicide.

Bi-polar disorder

People with bi-polar disorder typically experience episodes of very low mood (or depression) and high mood (or mania).

http://www.yourmentalhealth.ie/about-mental-health/common-problems/

TIP

Become familiar with the various supports that are available in your community so that you are ready to offer a suggestion in the event that someone reaches out to you!

Why Exercise? Why is it important? #

Exercise is important for everyone! For people with mental health issues, the benefits of regular exercise include:

• Reduce symptoms associated with anxiety and depression (Archer & Garcia, 2017)
• Enhance mood & mental well-being
• Improve quality of life
• Less fatigue & better sleep quality
• Better breathing (or deeper, more regular breaths)
• Improve coping skills and self-regulation (Lubans, et al., 2016)

Where do I start? Getting to know Someone with Mental Health Issues #

Since disability and impairment (including mental health issues) can be experienced so differently from person to person, this section highlights why the consultation phase is so important. Many fitness professionals are nervous about their first meeting. We hope this section will make you feel a little more comfortable and better prepared to manage this first step.

The Consultation #

Use the consultation as an opportunity to get to know your new participant. In addition to gathering medical information and details about their fitness/ physical activity experience, you talk about goal setting and learn about what they want, but it may be helpful for people with anxiety or depression to focus more on regular participation or the process of being active, rather than on achieving specific goals. In addition to talking about exercise, ask the participant about how they will get to the fitness center, and what kind of support (if any) they need to be ready to exercise (for example, accessing the locker room).

You want to support the participant to be as independent as possible. Depending on the individual, this may change over time as they become more familiar with the setting and feel more confident and capable. When someone with a mental health issue comes in for their consultation you may notice the following:

• They may tell you that they experience mental health difficulties or they may not
• They may look bored or uninterested, but it’s possible they’re having an off day or they are really tired
• They appear nervous or especially excited
• They may seem like they are no different from anyone else!

What are you going to do?

• Be patient. Listen.
• Ask the person how they feel. They may experience symptoms differently each day.
• Don’t worry about saying exactly the right thing. It’s important to build a relationship with the individual at this stage. Just be yourself. Be patient. Think about how you would like to be treated.
• It’s ok to ask about the kind of assistance they might need. For example, do they want you to check in with them each day? Do they prefer to exercise on their own? Again, be patient. Exercise may be new to them and the individual may not yet know what kind of support will work best for them!

Implications for Exercise #

People with mental health difficulties may or may not consider themselves to be disabled. This will vary across all people and all possible diagnoses. People with mental health difficulties may experience symptoms all the time, some of the time, or not very often and this may or may not have any effect on their participation in exercise. Your job is to provide the support they need to start and maintain an exercise program. Your job is not to be a counsellor or therapist.  Remember when we said that you should listen? Yes, that’s true, but not to the point that you feel as though you are playing the role of a therapist. Knowing what is available in your community will help you to re-direct the indivdual to support services that are out there.

Here are a few general tips to help you structure your exercise planning if you have a new participant who identifies as having mental health difficulties:

• Focus more on regular participation and the process of becoming active, rather than on setting and reaching specific goals. Too much emphasis on goal setting may increase the risk of failure, which means no more exercise for some indivduals.
• Encourage joy in movement. Help the person to enjoy physical activities that they may have once loved (or find new ones they have yet to experience!)
• Introduce and encourage opportunities to be active in a social setting (e.g., group fitness class). Be prepared to offer strategies to help them be ready for that first class (e.g., talk about what to expect, what to bring, what will happen)
• Recommend exercising during a quieter time of day to decrease stress and anxiety, especially if exerice is new for the indivdual!

(ACSM, 2016)

Don’t forget:

Every person is like every other person, like some other person, and like no other person.

Monitoring Exertion & Exercise Intensity #

It’s really important that people who are new to exercise learn how to monitor and describe how they are feeling or their response to exercise. One helpful way to do this is to introduce the Rate of Perceived Exertion (RPE) scale.  The smiley face RPE Scale or the OMNI scale (see below for examples of both) may be more suitable for participants with various disabilities than the age-predicted maximal heart rate (220 – age) (Stanish & Aucoin, 2007).

In the beginning, it is also recommended that participants measure their heart rate (using wearable technology such as a heart rate monitor may make this easier!). This information will help the trainer and participant to work together to learn about how the participant perceives their exertion during exercise and may help to inform programming strategies. For example, a trainer may encourage the participant to work towards a specific level of RPE, which can be complemented with information from the HR monitor to measure exercise intensity. Monitoring HR may also be useful in the event that participants are exercising at a level beyond the recommended intensity, which may happen if the participant is very engaged in the activity or trying to make a positive impression on the trainer.

OMNI Scale

Smiley Face Relative Perceived Exertion Scale

Medication & Exercise: What do you need to know? #

Although you will not be administering medication, it’s important that you have a brief conversation with the participant to make sure they are aware of any side effects of their medications that may impact their ability to take part in exercise and/or specific safety considerations.

Many individuals with mental health issues will take regular medications to manage their symptoms. It is recommended that you talk about this during the consultation to see if there are any side effects that you should be aware of. You may also want to check in with them each time they come in to see if there are any changes or any new information that you should know. The decision to share whether someone is taking medication is a personal one. It is only necessary that an individual share this information with you if there are direct implications (for example, are there any risks?) related to their participation in a fitness program.

Inclusive TIMES: Tips & Strategies for Individuals with Mental Health Issues #

The tips and strategies found within the inclusive TIMES section will help you to create an environment that will support your participant’s participation in physical activity as independently as possible. It is important that you involve the participant whenever possible, along the way to ensure the program that you design will meet their needs physically, as well as emotionally and socially. Introducing a few simple strategies such as scheduling sessions during quieter times of day or offering a written outline of an exercise program, will increase an indivdual’s comfort level with their new fitness program. Ultimately, they will gain confidence and belief in their abilities (increasing self-efficacy) and experience self-determination (sense of control over their own destiny). This is key to establishing healthy habits that will be adopted for the long term.

Time #

• Send a reminder (e.g., text) about an appointment or exercise session
• Talk to the participant to find the right time of day to exercise (e.g., in the morning when they are fresh and ready to go or in the evening when they are looking to burn off energy from the day)!
• Begin with shorter duration and lower intensity activities, progressing gradually to moderate intensity.

Instruction #

• Be patient.
• Provide clear, simple instructions in more than one format (e.g., verbal and visual).
• Use clear, simple verbal cues to encourage proper form
• Introduce the RPE Scale and teach participant to learn their body’s response to various intensities. This will help them become aware of what intensity is appropriate for the body on any given day.
• Focus on participating rather than having perfect form. You want to help them establish regular active habits.

Movement #

• Suggest regular aerobic exercise to expend energy (in some cases this may reduce the need for medication).
• Recommend a group exercise class that focuses on stretching, mindfulness or meditation, such as yoga or tai chi that might help with managing stress or anxiety

Environment #

• Take a look at the exercise space- Is it motivating? Are there positive messages available (e.g., posters and images on the wall)? Is there information readily avilable on mental health supports?
• Work with allied professionals to reassure the participant that their programme is safe. It’s important that the participant feels safe and supported in their fitness programme.
• Remove clutter and extra equipment and ensure the space is clean to encourage focus and mindfulness during exericse

Support #

• Use the consultation to discuss the desired level of support for the individual (this will be unique to each participant).
• Social support is vital to promote a healthy lifestyle! Introduce activities with partners to create a positive, fun & enjoyable atmosphere that is motivating. Take a moment to introduce the participant to staff and other health club members to help them feel welcome the next time they come in!
• Be familiar with local supports that are available for people with mental health issues and be prepared to direct participants as needed.
• Discuss the participant’s overall lifestyle choices (e.g., nutrition, sleep hygiene), to identify areas where they can enhance their overall health. For example, does the participant smoke? Eat healthy? Are there changes you can suggest?

References #

• Archer, T., & Garcia, D. (2017). Physical exercise ameiliorates sypmtoms of anxiety and depression. Sports Medicine Rehabilitation, 1, 1.
• Autistica (2017). Mental health in autism. https://www.autistica.org.uk/research/mental-health/ (Accessed on 24^th August 2017)
• Canadian Society for Exercise Physiology (CSEP). “Psychology Works” Fact Sheet: Physical activity, mental health and motivation. Available at: http://www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFactSheet_PhysicalActivity_MentalHealth_Motivation.pdf (Accessed 16th August 2017)
• Canadian Society for Exercise Physiology (CSEP) (2002). Inclusive Fitness and Lifestyle Services for All disAbilities.
• Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9^th May 2016]
• Moore, G., Durstine, L., and Painter, P., eds. (2016) American College of Sports Medicine: Exercise Management for Persons with Chronic Diseases and Disabilities, 5^th Edition, Human Kinetics, Champaign
• For resources related to youth and mental health: Fredeen, D. (2016). Move your mood. https://www.centre4activeliving.ca/news/2016/02/move-your-mood-youth-mental-health/ Accessed 16^th August 2017
• Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9^th Edition, Baltimore: Lippincott Williams & Wilkins
• Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7^th Edition, Baltimore: Lippincott Williams & Wilkins
• WHO Global Action Plan 2013-2020, available at:

http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf [accessed 12th July 2016]

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