Belinda Exercise Therapy and Health Education with a Client Suffering from Mental Health Illness Executive Summary The positive effects of exercise therapy and health education on mental wellbeing are proven to be beneficial in many studies that have been completed. In an article written by The Heart Foundation (2007), it details benefits such as decreased feelings of depression, stress and anxiety over the long and short term from regular physical activity. For many who are suffering from a mental illness, the symptoms associated i.e. negative self-talk, social anxiety and low self-esteem may be inhibiting them from undertaking an exercise program in the first instance and therefore are solely relying on traditional treatment methods such as prescribed medication to manage their disease/s. With a lack of physical activity, additional improvements in mental health is not achieved outside the usual scope and the increased risk of other major health concerns such as obesity and type 2 diabetes become apparent. In a journal completed by Zschucke E et.al (2013), it discusses the increased incidence of the comorbidity of various physical health conditions such as respiratory or cardiovascular disease in mental health patients due to an unhealthy / inactive lifestyle. Mental illness, in its many forms comes with startling statistics within Australia alone particularly in the form of anxiety / depression where: 1 in 4 will experience anxiety in their life Over a 12-month period over two million people will have some form of anxiety For those suffering both anxiety and depression, only 35% access any form of treatment Depression is the stand alone cause of disability across the world. Australian Bureau of Statistics, (2008) This case study will examine the benefits of exercise therapy in the form of functional movement with prescribed medication in a female who was diagnosed with mental health illness during her childhood. The exercise therapy methods and outcomes will be detailed with relevance to completed clinical studies and current research. Belinda is a 52-year-old female who was diagnosed with major depressive disorder, seasonal affective disorder (SAD) and anxiety during her childhood. Taking prescribed medication to assist in the treatment of the conditions, she still struggled daily with high stress causing increased symptoms and morbid obesity which reduced her quality of life. Constantly seeking options to increase her fitness and improve her health, Belinda sought exercise therapy in the form of personal training believing the accountability to a personal trainer would be a good solution. After much research via the internet, Belinda contacted Fitness Forever due to their focus on chronic health – disease prevention / management. Seeking weight loss to improve her mobility, Belinda was sceptical commencing her exercise program due to failed success in the past with exercise programs. After many years struggling with binge eating to cope with stress levels, Belinda has lead a lifelong struggle with weight loss – increasing her mental health symptoms and low self-confidence and body image. It was not until Belinda commenced a regular exercise training program and received basic health education with Fitness Forever that the benefits to her mental health started to show. Some of the key issues on the commencement of Belinda’s exercise program were: Mobility issues due to morbid obesity Severe anxiety Negative body image Long term history of binge / emotional eating Anxiety in relation to exercise ability due to size SAD during winter (darker / colder) High stress levels Social anxiety Major depression Mood disorder In order for Belinda to achieve her key goals / objectives of; Weight loss Committing to and maintaining a regular exercise routine Understanding the basics of functional exercise Achieving and maintaining a healthy weight Reduced anxiety and depression symptoms Working on prevention / management injuries It was essential to work with Belinda on the theory that exercise therapy and basic health education are beneficial in their relationship to mental health – potentially reducing the symptoms associated with anxiety and depression. Using this theory, the key goals and objectives should be achieved or at a minimum, noticeable improvements made. Belinda has been seeing a dietician and psychologist long term, so the basis of training would be teaching general teachings of functional exercise and how to use her body effectively to achieve her own goals. Findings Long term high stress levels On the commencement of exercise therapy, Belinda did not indicate the full effects that stress has on her life. Over the first few months, beginning to feel more comfortable and trusting with her trainer, she indicated that work stresses play a large role in her anxiety and depression levels causing binge eating and her wanting to hibernate at home away from the public eye. This has many carry on effects which affect her health including; Daily work stress causes Belinda to stop in at the shop on the way home from work to buy family blocks of chocolate which she will then proceed to consume over the course of the night. (Note: the exact quantities have never been stated aside from 1 whole family block). High stress levels trigger anxiety which on occasion has affected her training schedule whereby she has cancelled her upcoming training session the afternoon before due to feeling overwhelmed generally. Some instances during training, Belinda has come straight from work and has broken down crying during the session due to a stressful situation that has happened that same day at work. Fear of failing a long-term fitness commitment On commencement of exercise therapy, Belinda indicated that she had previously attended a weight loss retreat where she had varying success. She felt overwhelmed on occasion in the environment due to some participants appearing quite fit and healthy prior to starting the retreat. She felt that during some activities her size and mobility issues were not catered for and she often fell behind. Based on this, Belinda assumed that it would be difficult to find an exercise program that would be tailored specifically to her requirements. Belinda had never attended a gym or a personal training session and therefore found the concept very overwhelming and made her anxiety levels increase. She did many hours of internet research prior to finding Fitness Forever who catered for those with special needs which provided some comfort for her. Belinda finds it very difficult to engage in conversation with strangers due to her social anxiety. This fear has kept her from commencing an exercise therapy program previously on the premise that she would be forced to make conversation. Belinda has commented that she finds making conversation with her long-term hairdresser stressful and gets frustrated when forced to talk due to her mood disorder. Belinda has suffered many injuries due to her size prior to the commencement of exercise therapy and therefore was on occasion tempted to use them as an excuse to cancel a session. Injuries included inflamed Achilles and hip issues Muscle tension through the neck was also at times debilitating Before understanding the full extent of Belinda’s anxiety disorder, she was requested to perform a standard fitness test, this posed individual problems; The pressure of a fitness test caused anxiety symptoms Her apprehension during the test skewed results due to her anxiety She had limited trust in her trainer’s ability and thought she would be pushed past her individual limit fearing that she may injure a body part further Depression in winter months – SAD; SAD affects Belinda in such a way that during the winter months where the days are shorter and darker her depression heightens and motivation decreases. This caused a slight increase in session cancellations. Discussion For the past 50 years, Belinda, has struggled with a mood disorder, SAD, anxiety and depression which has impacted her health negatively, led to morbid obesity and a lifeline struggle with weight. Belinda came to Fitness Forever with a positive attitude in changing her exercise habits and health for the better, however, a day to day battle with her mental health issues and high stress levels has impacted her results. A steady positive progression can be followed by a period of heightened anxiety and depression symptoms leading to binge eating and falling behind once again. The benefits of exercise therapy and generalised anxiety have been well documented over the years, particularly in articles like that of Ströhle, A. (2008) which discusses numerous benefits on generalised anxiety with exercise therapy consisting of 3-4 sessions per week for a minimum of 20-30min with moderate intensity. As discussed in an article by Deslandes, A. et al. (2009), the thought of exercise and performing exercises may be stressful for some individuals, however, moderate exercise in fact reduces harmful stress levels (i.e. that which is bought upon by work or personal life) while also improving quality of life and decreasing symptoms of mental health illness such as depression. While working with a client such as Belinda who suffers not only from major depression but also SAD, it’s important to remember that while dealing with regular symptoms of depression every day, during autumn/winter, Belinda, (as per article by Roecklein, K. & Rohan, K., 2005) is more than likely to have an increase in severity or onset of symptoms such as increased appetite, fatigue and hypersomnia which will affect her exercise performance, commitment to the program and general attitude. Various considerations must be given to clients suffering SAD which are outlined in the same article by Roecklein, K. & Rohan, K., (2005) such as time of day exercising i.e. morning exercise will induce phase-advance (improving circadian rhythms) and exercising outside in the daylight will provide some benefits similar to light therapy. Aerobic activity i.e. bike cycling (including 5min warm up, 10min normal cycling followed by 10min 78% maximum heart rate x 2 (with a 5min rest in between sets)) will help reduce symptoms of SAD such as hypersomnia as it increases oxygen consumption, transferring more oxygenated blood around the body. For Belinda to achieve success, it is imperative for the trainer to be flexible and have a good understanding of not only the effects of anxiety, depression but also SAD and the role it will play during a long-term training program. For Belinda, communication is vital so she understands what is expected of her during a training session. The trainer is to provide a clear demonstration of how to perform the exercises (modifying where required due to size or physical ability). It is essential for Belinda to work within her means and not be put under pressure or forced to feel inadequate or sub-class during any session. The trainers attitude and empathy towards a client such as Belinda is as important as the training itself as social anxiety, major depressive symptoms and SAD have the potential to cause the client to cancel or at worst cease their training program. Verbal and written communication is imperative including pre-session confirmation, positive post-workout reinforcement and providing feedback where required. A variety of exercise styles and types in Belinda’s training will also provide her with an increased chance of improvements which should be seen in both her physical and mental health. Conclusion & Recommendations In order for Belinda to commit to her goal of a regular exercise program, her physical capabilities must first be assessed by way of a fitness test. A modification of the standard test would be required with modified exercises e.g. floor push ups to wall push ups, regular step ups to reduced height step etc. This will demonstrate in the first instance to Belinda, that she is able to complete various exercises during the first session providing her with confidence to return. During the initial consultation it would be advised not to overwhelm a client such as Belinda with information or technical terms, instead use positive reinforcement on how these exercises are assisting her functional movement. Belinda is aware that she is morbidly obese and has been informed by her GP of the associated risks which is why she is changing her lifestyle to include a regular exercise program. The focus for Belinda during her exercise therapy program should not be specifically on weight loss as this adds increased pressure and anxiety, instead, each session introducing new exercises which will allow Belinda to increase her functional movement, remain interested in her program and improve not only her fitness level but the symptoms of her mental health conditions. For exercise to benefit the symptoms of anxiety, depression and SAD, Belinda’s exercise program was structured as follows (with some recommendations taken from Ströhle, A. (2008)); 1 x 45min exercise session per week Varied exercises at each session Repetition focussed sets Modification of exercises Interval training to increase cardiovascular fitness Boxing to help relieve nervous energy Regular commendation of results achieved Gentle, yet steady increase in exercise intensity to improve overall fitness Fitness testing is completed on client’s request In order to achieve a regular exercise therapy program, it was believed that Belinda should complete just one exercise session per week with her trainer with additional exercise performed at home or with friends. Sessions were to contain a combination of cardiovascular, strength and flexibility exercises to improve the overall functionality of her movement and improve her life, making day to day activities easier. The risks of designing such a program with only one day per week training included; One session may not be enough to provide enough benefits to reduce mental health symptoms One session may not be regular enough to form a concrete exercise habit particularly if Belinda did not do additional exercise at home Proven health benefits have been demonstrated from various studies from only small amounts of physical activity therefore, allowing Belinda to still gain reward from just one session per week. After 50 years of no regular exercise program in place, the risk of Belinda feeling overwhelmed from delayed onset muscle soreness or feeling to much obligation meant that one session per week would provide her the benefits and solid foundations in creating a lifelong regular exercise routine. This exercise therapy program is designed to work in conjunction with the participants Psychologist and General Practitioner, particularly if the client is on prescribed medication or is undertaking CBT as it would be encouraged that they discuss the training sessions and outcomes during their sessions. At commencement of the program, the personal trainer is to detail the structure of the program to the client detailing what the sessions will involve i.e. cardiovascular / strength or flexibility training. A confirmation message would be sent prior to every session, and positive reinforcement given at the end of each training session. Results from testing would be provided within 24 hours of being undertaken with constructive feedback provided. The success of the exercise therapy program would be reviewed every two months and modifications to exercise prescription, session length etc. would be revised at this time. References Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Cat. no. (4326.0). Canberra: ABS. Ströhle, A. (2008). Physical activity, exercise, depression and anxiety disorders. J Neural Transm (2009) 116:777-784. DOI 10.1007/s00702-008-0092-x Deslandes A, Moraes H, Ferreira C, Veiga H, Silveira H, Mouta R, Pompeu F, Coutinho E. (2009) Exercise and Mental Health: Many Reasons to Move. Retrieved online 03.01.2018 from https://www.karger.com/Article/PDF/223730 Roecklein, K. A., & Rohan, K. J. (2005). Seasonal Affective Disorder: An Overview and Update. Psychiatry (Edgmont), 2(1), 20–26. The Heart Foundation. (2007). Physical Activity and Depression. https://www.heartfoundation.org.au/images/uploads/publications/Physical-activity-and-depression.pdf Zschucke E, Gaudlitz K, Ströhle A. Exercise and Physical Activity in Mental Disorders: Clinical and Experimental Evidence. Journal of Preventive Medicine and Public Health. 2013;46(Suppl 1):S12-S21. doi:10.3961/jpmph.2013.46.S.S12.