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Volume 49 Number 1
Edited by Geoffrey Nelson, Wilfred Laurier University
Written by Amy Shearer (firstname.lastname@example.org) Portland State University, Greg Townley (email@example.com) Portland State University, and Christina Overgard (firstname.lastname@example.org) Luke-Dorf, Inc.
Individuals served by the public mental health system die an average of 25 years earlier than the general public, largely from preventable diseases and suboptimal healthcare (Colton & Manderscheid, 2006; Mauer, 2006). In a study of Medicaid claims, 75% of people with serious mental illnesses had chronic preventable health conditions, such as pulmonary and smoking-related illnesses (Jones et al., 2014). Individuals with schizophrenia in particular have more risk factors for cardiovascular disease, including smoking, obesity, lack of exercise, and harmful levels of salt consumption (Davidson et al., 2001).
Individuals with serious mental illnesses also experience social risk factors. They often have fewer opportunities for engagement with the broader community (White, Simpson, Gonda, Ravesloot, & Coble, 2010); and when these opportunities are present, individuals face the added barrier of stigma. These factors contribute to social isolation, which in turn has been linked to all-cause mortality, physiological aging, and increased mental illness symptomatology (Hawkley & Cacioppo, 2010).
Programs to improve the physical health of individuals with serious mental illnesses have been successful (Brown, Goetz, & Hamera, 2014; Happell, Davies, & Scott, 2012; Osborn, 2001), and in some cases are as effective as psychotherapeutic interventions (Richardson et al., 2014). In addition to physical benefits (e.g. reduced BMI and blood pressure), commonly reported psychological benefits include decreased symptomatology, improved quality of life, and improved self-efficacy (Hawkley & Cacioppo, 2010). However, less is known about the impact of physical health interventions on social health risk factors (e.g., stigma and isolation).
Despite its benefits to mental and physical health, exercise continues to be under-utilized by mental health programs (Callaghan, 2004; Hawkley & Cacioppo, 2010). Recently, mental health consumer advocates have called for efforts to incorporate physical wellness into existing recovery programs (Fricks, 2010). Responding to this call, Luke-Dorf, a supportive housing mental health agency in Portland OR, developed and implemented the Healthy Eating and Active Lifestyle (HEAL) initiative for their residents. The intervention provides nutritious food options, individual and staff-led group physical activity, and health education. Residents are encouraged to set SMART wellness goals—i.e., goals that are specific, measurable, achievable, realistic, and time-bound (Bovend’Eerdt, Botell, & Wade, 2009). Thus far, over 400 residents have engaged in HEAL, averaging 220 staff-led activity minutes per week. This brief report focuses on the unanticipated social benefits of participating in HEAL, noted by numerous residents in a series of focus groups.
Four focus groups were conducted among 22 individuals with serious mental illnesses residing in six supportive housing sites in the Pacific Northwest. Purposeful sampling was employed to select participants from a variety of housing and treatment sites to maximize diversity of experience with the intervention. Sampling continued until theoretical saturation was reached. Resident focus groups ranged in size from three to eight participants. Residents ranged in age from 24 to 66 and had resided in their current housing for an average of 2.5 years, 64% were male, 75% of participants were White, and the majority (68.2%) indicated a schizophrenia-spectrum diagnosis. One focus group was conducted with housing staff to triangulate resident reports. Staff (N = 5) ranged in age from 28 to 60 and had been employed by Luke-Dorf for an average of 3.4 years.
After collecting informed consent, participants were asked to discuss general experiences with the HEAL program, their attitudes about health and wellness, and factors that help or hinder their healthy lifestyle. Focus groups lasted approximately 60 minutes and were audio recorded and transcribed verbatim. Participants were given a small cash incentive. We used thematic content analysis to determine central themes.
Findings highlight several important factors that influenced program engagement. In addition to improved physical health, participants noted increased opportunities for community participation, social support, and even perceived reduction in community stigma. We focus on these benefits below.
Community participation. Staff and residents reported that increasing physical activity encouraged them to participate more actively in the community. Residents reported more chance friendly encounters with community members while walking in the neighborhood to fulfill a fitness goal: “Getting out and about… I may meet other people when I walk in the way to the park… physically, my physical presence makes the difference.”
Other participants commented on the benefits of being challenged to have new experiences: “[You] have what you might call new experiences because just staying inside and being reclusive, you ruminate rather than express. It is more a challenge and an opportunity with getting out and about.” Similarly, another resident said, “It changes my mental focus on being more sociable with my family and kind of get to know the neighbors and… get to know other people and try to be involved in the community out there.”
Social support. A common theme among residents and staff was that HEAL fostered social relationships within the housing site. As one staff member noted, “Before [HEAL] they were just taking their meds or trying to go back to bed. We would try to engage with them, but… we didn’t have a plan to follow.” Participants particularly enjoyed group exercise because it brought residents together and created a sense of camaraderie: “I like the group exercise activities… playing volleyball with a big beach ball. You know, it’s fun… the way we interact.” Residents talked poignantly about cheering each other on during group sports:
There is that coming together. Maybe you can’t put into words exactly, but it is a common experience that…we kinda root for each other… we have fun bouncing the ball around the group… and it goes off this way, and someone unexpectedly isn’t ready for the ball. It hits them, and we laugh… I think the camaraderie and the atmosphere and mood level in the house is better.
Exercise was also noted as an opportunity to get to know new residents:
We just got a couple of new guys, and one of the staff and myself and both the new guys went on a walk and got a chance to talk to them a little bit. I think next week we are going to go pick blackberries.
Other HEAL group activities, such as communal meal preparation, had similar perceived benefits:
I really enjoy Fridays which they bring basically raw meat… and we cook it together… we agree on something. There’s more of a sense of ‘oh, I’ll do the potatoes,’ ‘oh I’ll do the broccoli or salad’… we all come together and cook a meal.
Staff and residents appreciated that HEAL gives them an opportunity to interact with one another absent of formal roles. One staff member commented:
It’s nice to have fun with them. To be honest, sometimes it’s almost like they think we are superior to them or above them. When you are playing a game, no one is superior and everybody is having fun, so it is really nice to kinda just be humans.
Residents also viewed these closer relationships with staff as a benefit: “It brings the community together and it seems like we have more of sense of a house that way. We get to interact with staff and stuff, and that’s really nice.”
Social support was particularly important in encouraging individuals to set and meet health goals. This process appeared to be cyclical, in which group activities strengthened friendships and participants would then encourage and cheer each other on, thereby increasing engagement:
R1: …When you walk with people, you can talk and it makes it go faster. Somebody else must be walking faster than you and you’ll be able to pick up their pace and maybe go a little faster.
R2: You can push them or they can push you. One more rep.
Stigma reduction. Participating in outdoor HEAL activities also helped to normalize relationships with neighbors and reduce some of the perceived stigma associated with living in the housing site. Neighbors could see residents engaging in relatable games and cheer players on, or even join them. Staff noted that rather than only going outside to smoke cigarettes, residents now spent more time outside engaged in healthy activities:
Now we have more active people than we have smokers, and the neighbors will comment on shots made or playing soccer; and it really has normalized their relationships with their neighbors. I think that has gone a long way to feel like we have a legit place in this neighborhood.
Residents also noted this increased sense of belonging: “I think that the healthier I get, the more I fit into the community… I meet other people that are healthy.” Residents also appreciated the nature in which HEAL acts as a socializing agent, facilitating their interactions in the broader community: “[HEAL] helps because you learn… how to be accepted out in society.”
Conclusions and Implications for Practice
Our findings illustrate the importance of attending to diverse outcomes when examining the effectiveness of health and wellness interventions for individuals with serious mental illnesses. Participants largely reported increased opportunities for social support, strengthened friendships, more active participation in the broader community, and decreased perceptions of community stigma. These findings are particularly relevant as mental health policy has shifted over the last decade to an emphasis on providing services to assist persons with mental illnesses to live, work, socialize, learn, and participate fully in their communities (Townley & Sylvestre, 2014). Future physical health programs should incorporate and measure facets of social support, community participation, and stigma reduction in addition to more traditional physical health indicators. The role of physical health interventions in normalizing relationships between individuals with serious mental illnesses and members of the broader community is particularly encouraging and should be a focus of future studies.
The limitations of our small sample size and restricted geographic scope must be noted. However, while our specific findings cannot necessarily be generalized to all individuals with serious mental illnesses, the importance of attending to the social benefits of participation in health interventions transfers across setting and sample. Programs that operate out of different settings can apply the findings in a similar way by focusing on group exercise and shared community activities. Our findings also suggest that health interventions can strengthen cohesion between mental health consumers and staff, contributing to an organizational culture of health, wellness, and inclusion.
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