The role of sport and exercise in recovery from serious mental illness: two case studies.

The role of sport and exercise in recovery from serious mental illness: two case studies.

Article Type:	Case study
Subject:	Medical research (Reports) Medicine, Experimental (Reports) Sports (United Kingdom) Sports (Psychological aspects) Exercise (Psychological aspects) Mental illness (Care and treatment) Men (Health aspects) Men (Management)
Authors:	Carless, David Douglas, Kitrina
Pub Date:	06/22/2008
Publication:	Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Men's Studies Press ISSN: 1532-6306
Issue:	Date: Summer, 2008 Source Volume: 7 Source Issue: 2
Topic:	Event Code: 200 Management dynamics Computer Subject: Company business management
Product:	Product Code: 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs SIC Code: 8730 Research and Testing Services
Geographic:	Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom

Accession Number:	186225542
Full Text:	Despite continuing interest in the physical activity-mental health relationship, few studies have recently been published concerning the effects of exercise for men with serious mental illness. This study helps fill this gap through an interpretive approach that explores how sport and exercise can contribute to recovery from mental illness. Case studies of two men's experiences are presented that illustrate two distinct roles sport and exercise can play. In the first case, sport and exercise are central to the participant's identity and fundamental to his sense of self. For this individual, returning to sport and exercise following remission of psychotic symptoms represents a return to intrinsically meaningful activities. In the second case, sport and exercise are used as a tool or vehicle for desired outcomes that facilitate personally meaningful vocational activities. For this individual, sport and exercise represent a fresh start and a worthwhile use of time. Keywords: mental health, schizophrenia, physical activity, case study, exercise, sport ********** The mental health benefits of sport, exercise, and physical activity are a topic of continuing interest reflected in the ongoing publication of research in this area (e.g., Craft, 2005; Faulkner & Biddle, 2004; Stathopolou, Powers, Berry, Smits, & Otto, 2006). While studies continue to be published concerning the psychological effects of physical activity for men with mild to moderate mental health problems such as depression and anxiety, few studies focussing on the effects of exercise for men with serious mental illness [1] have been published (Richardson, Faulkner, McDevitt, Skrinar, Hutchinson, & Piette, 2005). This may be an oversight as existing research suggests sport and exercise can provide several benefits for men with serious mental illness such as schizophrenia. In their review of the literature on exercise and schizophrenia Faulkner and Biddle (1999) noted that: The small number of studies published since Faulkner and Biddle's review support the potential of sport and exercise to alleviate symptoms of mental illness (Beebe, Tian, Morris, Goodwin, Allen, & Kuldau, 2005) and suggest that sport and exercise can provide other benefits for men with serious mental illness such as valued opportunities for social interaction and support (Carless & Douglas, 2004; Carter-Morris & Faulkner, 2003; Fogarty & Happell, 2005), while helping them feel more energetic, less stressed, and to sleep better (McDevitt, Snyder, Miller, & Wilbur, 2006). A key reason for the small number of published studies is the considerable difficulties that arise when conducting physical activity research in the context of serious mental illness (for further discussion, see Carless & Faulkner 2003; Faulkner & Biddie, 1999; Faulkner & Carless, 2006). In particular, several issues make conducting traditional research designs such as clinical trials problematic: Further, according to Martinsen (1995), although self-report questionnaires are used widely with other populations, they are not considered reliable with psychotic patients. The combination of these difficulties has led Faulkner and Sparkes (1999) to comment: As a consequence of these issues, Faulkner and Biddle's (1999, p. 453) recommendation that "further research of both a quantitative and qualitative nature is urgently needed to examine the efficacy of exercise as therapy" has largely been unheeded. Indeed, their sentiment has recently been echoed by Fogarty and Happell (2005) who reiterate that "further research into the impact of regular exercise for people experiencing a long-term mental illness is warranted and indeed urgently required" (p. 349). A Recovery Perspective Within the field of mental health a notable shift is taking place in terms of what recovery from mental illness entails. Traditionally, the focus of interventions for people with serious mental illness has been on alleviating symptoms, deficits, and dysfunctions primarily through medication (Chadwick, 1997; Repper & Perkins, 2003). However, while modern medications may be effective in this regard, those who have experienced serious mental illness often assert that something more than remission of symptoms is necessary for recovery to take place. Peter Chadwick. a psychologist who has first hand experience of serious mental illness, recalls how "despite the quite incredible power of the medication to wipe out symptoms (for which I will always be grateful) the inner feelings of downheartedness and guilt were still there" (1997, p. 48). In this regard, Julie Repper and Rachel Perkins, both of whom have also experienced mental illness, comment, "Recovery is not about 'getting rid' of problems. It is about seeing people beyond their problems--their abilities, possibilities, interests and dreams" (p. ix). From the perspective of those who experience mental illness, alleviation of symptoms is only one part of the recovery picture. As the quote above suggests, a further aspect of recovery is the opportunity to enact, acquire, and demonstrate ability while pursuing personal interests, hopes, and aspirations. When it is recognised that "serious mental illness threatens personhood and the self because it can affect every facet of life" (Kirkpatrick, Landeen, Woodside, & Byrne, 2001, p. 47), recovery can be seen as a broad concept related to a person's life experiences in a holistic sense. As Anthony (1993) has observed, The recovery process, therefore, is unique to each individual being dependent on situational and contextual factors and individual life experiences. In this regard, Coleman (1999) has argued against defining recovery in terms of standardised outcome measures such as symptom rating scales and quality of life scales on the basis that they may hold little meaning for individuals and fail to allow for the personal and subjective nature of recovery. To date, the literature on exercise and serious mental illness has not addressed the potential for exercise and sport to contribute to recovery in a positive sense. Research has tended to focus on the ways exercise may alleviate symptoms, impairment, and dysfunction rather than its potential to contribute meaning, purpose, success, and satisfaction to a person's life. In terms of researching how exercise can contribute to mental health, Crone, Smith, and Gough (2005) suggest, "researchers have concentrated on establishing a relationship, rather than asking why a particular incident, experience or situation is important" (p. 601). Thus the ways in which exercise and sport may help an individual recover from mental illness--by changing attitudes, values, feelings, goals, skills and/or roles or providing a way to live a satisfying, hopeful, and contributing life--are yet to be explored. Purpose of Research The purpose of this research is to develop our understanding of the role/s of sport and exercise in contributing to men's recovery from serious mental illness. To this end, the research approach must be capable of fulfilling three fundamental requirements. First, given that the recovery process is likely to be unique to each individual (Anthony, 1993) it is necessary to adopt an idiographic focus to shed light on the experience of sport, exercise, and mental illness at the personal level. Second, in terms improving understanding of how men experience (and recover from) mental illness, "it is the meaning and context of the issues within people's lives that forms the basis of our understanding" (Mental Health Foundation, 2000, p. 8). Hence, in-depth study of individuals is necessary in order to understand how sport and exercise may hold meaning within the broad context of a person's life experiences--to explore why certain incidents, experiences, or situations may be important to that individual. Finally, investigating recovery as a "process of changing one's attitudes, values, feelings, goals, skills and/or roles" and living "a satisfying, hopeful, and contributing life" (Anthony, p. 19) necessitates a primary focus on subjective experiences and processes over the life course rather than objective, measurable outcomes or end points. An interpretive approach is well suited to these needs allowing researchers, as Crone et al. (2005) recommend, "to specifically investigate the physical activity and mental health relationship from the perspective of the participants who experience it" (p. 601). Method The methodological approach influencing this research is interpretive interactionism (Denzin, 1989). Mohr (1997) suggests that interpretive interactionism is an approach to studying the whole person from multiple perspectives within her or his socio-cultural and historical context. Two case studies (Stake, 1995) were conducted to gain an in-depth understanding of individual experience from a variety of perspectives in recognition of the unique nature of participants' personal background, experience of mental illness, treatment programme, and sport/exercise experiences. As Stake suggests, case study allows the development of understanding and insight through in-depth examination of a few individual lives. Participants and Recruitment Following ethical clearance from the local NHS Trust research ethics committee, the lead researcher (David Carless) began an 18-month period of immersion in the daily life of a vocational rehabilitation centre for people with serious mental illness. During this time, David took part in sport and exercise groups as well as social and day-to-day activities that helped build trust and rapport with potential participants. As part of a larger study (Carless, 2003), two male participants were identified through purposive sampling (Glaser & Strauss, 1967) facilitated by close liaison with mental health professionals. These men: (i.) had personal experience of both serious mental illness and sport/exercise participation; (ii.) were willing to take part in the research; and (iii.) were considered by health professionals to be sufficiently mentally well to participate in interviews. The participants had been mental health service users for 15 and 18 years, respectively; and their diagnoses included the term "schizophrenia" or "schizophrenic illness." Both men were receiving anti-psychotic medication, were unable to live independently or engage in paid employment, and were taking part in sport/exercise sessions organised by health professionals at the rehabilitation day centre that were an integral component of their scheduled weekly activities. Both provided informed consent and, to protect anonymity, both are referred to by pseudonym. Data Collection Given the severity of the participants' mental illness, the researchers and mental health professionals were anxious to minimise the risk of participants experiencing distress through taking part in the research. In particular, "formal" tape recorded interviews were identified as potentially problematic. For example, one participant suffered from paranoia that made the experience of conducting a formal, tape-recorded interview potentially threatening. To minimise these risks, we drew on the techniques of ethnographic research by collecting data through alternative approaches to avoid multiple interviews with each participant. Participant observation. Over an 18-month period of immersion in the field, David engaged in participant observation and "informal" interviews (i.e., conversation and general interaction) during sport and exercise activities and day-to-day life at the rehabilitation centre. These interpersonal exchanges were recorded in a research diary, on contact summary sheets, and through personal memos all of which provided valuable insights into each participant's experiences. Medical records. Given the importance of contextual factors in the exercise-mental health relationship (Faulkner & Biddle, 2004) and the diverse issues that influence mental health and illness across the lifespan, it was important to develop an understanding of each participant's medical history and background. As long-time mental health service users, each participant had extensive medical records that documented the course of their illness, treatment approaches, and lifestyle issues alongside records of their sport and exercise participation. Analysis of these medical records provided a chronological account of each participant's psychiatric history that reduced the need to dwell on previous moments in participants' lives that could be traumatic for participants to revisit. Interviews. A single in-depth, semi-structured interview was conducted with each participant once a familiar relationship had been developed between the participant and the lead researcher. The initial interview schedule began with four questions about current physical activity participation. A second section focussed on previous sport and exercise prior to mental illness. A third section sought descriptions of the effects of sport and exercise as experienced by the individual. The final section explored potential explanations for these effects. Descriptive questions (to learn about the participant's experiences), structured questions (to investigate specific details of these experiences), and contrast questions (to clarify and check meaning and interpretation) were used throughout the interviews in an effort to generate a comprehensive and complex understanding of individual experience (Biddle, Markland, Gilbourne, Chatzisarantis, & Sparkes, 2001). These "formal" interviews were recorded and transcribed verbatim. Additionally, further interviews with mental health professionals (care-coordinator, physiotherapist, and exercise leader) who worked closely with each participant were conducted to provide alternative perspectives on the participants' experiences from the point of view of health professionals who had known the participants for several years. Analysis and Interpretation A close reading of all interview transcripts and field notes was conducted to become immersed in the data (Maykut & Morehouse, 1994). During this process, margin comments and analytic memos were noted to highlight potentially significant issues. A content analysis was then conducted to identify and code themes arising from the data and quotations were used as the unit of analysis (Sparkes, 2005). A second stage of analysis involved compiling the obtained codes, relating to the specific theme and the location of the quotation within the transcript, on a single, large-scale mental map (Ryan & Bernard, 2000). The mental map allowed the co-ordination and linking the biographical data from the participant's medical records with interview data, contact summary sheets, research diary, and analytic memos. A third stage of analysis involved the development of a series of charts and matrices for each participant to chart changes in mental health and sport/exercise experiences over time. These one-page displays "show reduced, organised, and focused data on a single page" (Miles & Huberman, 1994, p. 93) and provided a manageable visual representation of key life experiences of each participant from the complex and multi-layered sources of data. These charts and matrices were used to inform the writing of a case study for each participant. The aim of each case study is to communicate, through thick description, an understanding of the meaning and value of sport and exercise within the context of the individual's life experiences. As Stake (1995) has suggested, "We do not study a case primarily to understand other cases. Our first obligation is to understand this one case" (p. 4). A triangulation process helped generate a complex, believable, and fair description of each individual's experience. The inclusion of multiple data sources (interviews with participants, interviews with mental health professionals, participant observation, and analysis of biographical data in the form of medical records) generated a richly complex picture of the roles of sport and exercise in the participants' lives. However, as Wolcott (2001) has suggested, the process of triangulation is often problematic and case reports can never be considered a "water tight argument" (Creswell, 1998, p. 198). As such, we subscribe to Lather's (1991) suggestion that the case reports be considered "a more open narrative with holes and questions and an admission of situatedness and partiality" (c.f. Creswell, p. 198). Our intention, therefore, is to present an account that is believable, credible, and authentic and which invites the reader to "relive the experiences of the individuals" (Faulkner & Biddle, 2004, p. 6). In so doing we encourage "trust to be shared with the reader in interpreting and evaluating the cases while, it is hoped, inviting consideration as to some of the dilemmas faced by the individuals concerned, from the reader's own experiential and theoretical perspectives" (Faulkner & Biddle, 2004, p. 6). With these points in mind, we now present case studies of the two participants, Colin and Mark. Each case study begins with a brief biography detailing the individual's mental health history from his medical records. A second section provides David's initial impressions of each participant formed while taking part in a weekly five-a-side football (soccer) group organised by staff at the rehabilitation centre. The third section explores the men's activity experiences with the intention of communicating two different roles that sport and exercise can play in recovery from serious mental illness. A Case Study of Colin: "I've Just Always Been Mad on Sports" A Brief Biography Having left school at sixteen, Colin was in employed full-time and living with his parents when his first documented mental health problems occurred in his late twenties. Colin was admitted to hospital and diagnosed with "schizophrenic illness with marked negative symptoms or a depressive illness." On discharge, Colin went home to live with his parents, returned to his previous employment, and experienced no further documented problems for five years. Following a death in the family, however, Colin was readmitted to hospital and a lengthy period of serious mental illness began. Over the next two years Colin was hospitalised on three further occasions and treated, during these lengthy admissions, with anti-psychotic and anti-depressant medication and electro-convulsive therapy. Following his final hospital admission, Colin was referred to a vocational rehabilitation centre. By now Colin was no longer experiencing delusions, hallucinations, or suicidal ideation. He was, however, continuing to experience prominent and debilitating negative and affective symptoms that included mood disturbances and low levels of motivation. A neuropsychological report noted widespread impairment of brain function that was not interpreted positively in terms of Colin returning to work. By the time Colin reached 40, he was living in the community with the support of a Community Psychiatric Nurse (CPN) and scheduled to attend the rehabilitation centre two days a week and a work scheme three days a week. Colin's medical records report that his attendance was poor despite daily visits or phone calls from a CPN and observed that his "'mental state remains very stable with no reports of psychosis or depression although his motivation for any change or increase in activity remains an issue." According to his care co-ordinator (Lynne), Colin at this time had "very poor eye contact, rarely said a word to anybody" and was far from recovered. First Impressions Colin took an active and vocal role in organising and encouraging his team and, in contrast to some group members who played in jeans and tee shirts, wore the kind of kit professional football players wear. He was enthusiastic and serious about the game and I thought he had probably played a lot of football before because although he was overweight he compensated for a lack of speed with an understanding of the game that allowed him to play a dominant role for his team. I soon formed an impression of Colin as a person for whom football, and sport in general, was important. This impression was strengthened when he arrived for our interview wearing his football kit and carrying a plastic bag containing three framed photos of himself playing for a local club, a scrapbook with photos of friends from various activity and sports groups, and some sport trophies. As he had promised the previous week, Colin had prepared for the interview by writing three pages of "things I wanted to say" related to sport and exercise. Colin's Sport and Exercise Experiences Colin's enthusiasm for football is noted in the records of his first hospital admission and he often talked about his love of football that can be traced back to his childhood years: Regular competitive football for a local club continued through Colin's early adult years and, in addition to matches and training, he cycled, swam, and played cricket. This activity was important to Colin and when he describes his top score in cricket (170 not out) as "one of my great moments," he indicates the high value he attaches to both the sport itself as well as his skilled performance. In contrast, Colin provided a blunt description of the onset of mental illness: "I just had a breakdown and that was it really.... Just anxiety, stress, work, everything like--just done too much." He abruptly moved from an active lifestyle to complete inactivity in hospital: It was several years later during an extended stay in hospital that Colin described reengaging in physical activity: "I started going to gym and went to OT [occupational therapy] and then I started going swimming--that was it then. It wasn't so bad then. I was actually on the road to recovery." Colin describes this initial exercise as giving him "a lift," which he likened to the effects of the anti-depressant medication he was taking. As he put it, "When I took it [the medication] it gave me a lift. But when I was doing exercises it was similar to that. It gave me a lift similar to what I was on with the [medication]." Colin's next involvement in physical activity was in the context of activity groups at a vocational rehabilitation centre and his descriptions of these sessions suggest sport and exercise provided a connection with his previous life prior to mental illness: "I went back again, started playing again.... I've just always been mad on sports ... the sort of games that I played in the past when I was younger, I sort of started back playing them again." In Colin's terms, engaging in sport and exercise meant, "I was back," back to sport and back to what was, for him, a normal life. An important factor concerns Colin's perceived ability, talent, and competence in sport. Lynne described how sport and exercise groups provided Colin an opportunity to display publicly his ability: Through displaying competence, Colin was able to experience satisfaction and a sense of achievement in sport contexts: "It [sport] brings all your talent out ... your ability in other words. It brings the, say, the cleverness out of you ... and I get satisfaction from that." Sport and exercise do not disappear from Colin's life when the activity session ends but permeate his life in quite profound ways. Colin's sport-related possessions testify to the importance sport has held throughout his life. For example, Lynne described the interior of Colin's apartment: "There's loads of his memorabilia about, especially sporting memorabilia actually, lots of things that he's won in school, photos of him in various teams." In conversation, Colin often referred to sporting experiences as being among his most valued and important moments. Showing me a photo he'd had taken professionally (of himself before a match in his team tracksuit) he remarked: "That's one of my favourite photos ... I wanted the game videoed but it was too expensive so I ended up having that done." In remarks such as this, Colin demonstrates how sporting moments comprise some of his most precious and happy memories. The way sport permeates Colin's life is also reflected in many of his relationships being formed and maintained through sport. In Lynne's words: "Surprisingly for someone with such a long-term history of mental illness, he's got a big social network of friends--around the football team, around the cricket club." Colin valued these relationships highly and, in relation to his skittles team, commented: "It's like a family really--I've been with them for so long." Lynne's response to a question about whether Colin's commitment to sport and exercise had led to any adverse effects reveals how relationships formed through sport provided Colin with potentially valuable social support that extended into areas of his life outside sport: A striking change in Colin had been the extent to which he had begun to take control of his own life. Lynne contrasted Colin's recent behaviour with other service users: Colin's descriptions of earlier years of illness portray a dependent and passive individual for whom decisions (in terms of hospitalisation and treatment, for example) were made for him rather than by him. For example, in the excerpt that follows the tone of the italicised phrases (things being done to him) contrasts sharply with Lynne's description of Colin initiating and maintaining sport and exercise activities for himself: Lynne saw Colin's continued and varied sport and exercise involvement as central to his progress toward recovery in a holistic sense. In her words: This more optimistic view of the future and a greater enthusiasm for life in general may be an important factor in Colin's chances of making a full recovery and returning to independent living. In this regard, the significance of sport and exercise in Colin's ongoing recovery is perhaps most clearly communicated in his response to a question of what had led to his improved mental health: A Case Study of Mark: "It's Not Made Me Into a Different Person ... but I Feel a Bit More Energised, a Bit More 'With It' Than I Did Before I Started" A Brief Biography In his early forties, Mark has an 18-year history of serious mental illness diagnosed as schizophrenia with major depression. Over the years, Mark has had several lengthy hospital admissions and been treated with a variety of anti-psychotic medications as well as, during the early stages of illness, electro-convulsive therapy. He continues to take anti-psychotic medication although there have been periods when he has discontinued medication himself, troubled by side-effects such as loss of concentration and, in his words, feelings of "fuzziness." Mark's medical records document several relapses and re-admissions to hospital alongside long-term "cognitive difficulties" and "deficits in interpersonal skills." Prior to becoming ill, Mark attended college but, on leaving, had difficulty finding work and was unemployed for four years. It was during this time that he was first treated for mental health problems. Mark's employment difficulties continued and he reports just one three-month period of employment since the onset of mental illness. Three years before starting at a rehabilitation centre, which he now attends five-days-a-week, Mark was involved in a single incident that resulted in him being detained under the Mental Health Act. Detention required him to move from his own fiat to an in-patient mental health residential ward and prevented him taking part in independent activities outside the ward. The only activities possible for Mark were those offered by mental health professionals. Although staff reported no problems or difficulties working with Mark, he was recorded as being socially withdrawn, resisting emotional contact with other residents and centre staff. Since starting at the rehabilitation centre, Mark's medical records report increasing participation in a range of vocational and social activities as well as daily participation in several forms of sport and exercise. At the time of the research, Mark's mental health was recorded as "stable" with no signs of psychotic symptoms or major depression. He was continuing to self-administer his anti-psychotic medication with no reports of compliance problems. It is noted in his medical records that Mark saw himself as "recovering." First Impressions Mark struck me as a quiet, reserved individual who behaved in a subdued but dignified manner. Of average build, Mark did not appear unfit but on the football pitch he moved slowly and little, tending to stay in one area of the pitch until the ball came to him. Although he always played a part in the games (watching the ball, making passes and tackles, scoring goals sometimes) he tended not to become emotionally involved, seemingly removed from the action and outside the "banter." He would respond in a friendly way to conversation started by another, but I rarely saw him initiate conversation or engage in more than brief interactions. In an interview context, in a private room with a tape-recorder, I sensed Mark's demeanour darken; he was less outward going, gave brief responses to questions, and at times left me feeling that certain issues were not topics he wished to discuss. Mark's Sport and Exercise Experiences Although Mark described an enthusiasm toward sport during his childhood years, playing football at school and on weekends, his participation ceased when he left school. Of the time Mark became ill until the time he began exercising at the rehabilitation centre, a period of around 18 years, Mark said simply: "I wasn't into exercise during that period. Just wasn't." Seven months before this research began, Mark started exercising at the rehabilitation centre describing his activity as "starting afresh." He described how this change came about: Mark's remarks suggest his initial participation was motivated by a desire to get fitter and that this was related to his newfound valuing of physical health and fitness: "Well, I'm older, hopefully I'm wiser about the body. I realise it's important to be fit, to look after your body.... Since I've had a mental illness I've realised that sport--exercise--is important." After six months of participation, Mark begun to perceive fitness improvements that he noticed in the context of other activities: "I'm a bit fitter than I used to be. Like doing the wood work, I can saw pieces of wood easier." As Mark put it, exercise "helps me build up my strength for digging the weeds in the allotment ... it's made me feel stronger, capable of doing the gardening." A second factor in Mark's participation was his belief that by exercising he was using his time constructively. Mark's life prior to his involvement in sport and exercise was characterised by inactivity--in terms of physical, occupational, and social activity. As Mark put it, "I realised that I could use my time better.... That's important I think--to actually be able to use your time properly.... I've got the time to exercise so I use it." Sport and exercise kept him busy and this, for Mark, was a good thing: "Busy--I like it like that." Further, because he valued health and fitness, and believed exercise would contribute, Mark gained a sense of satisfaction that he was spending his time doing something worthwhile. Social and interpersonal difficulties, noted in Mark's medical records as a longterm problem, began to show signs of improvement alongside Mark's increasing activity. Simon [exercise leader] described his initial impressions of Mark: "At first he would only give one word answers.... I thought he was very quiet and very wary." After several weeks of attending the football group Simon noticed changes in Mark. In the context of the five-a-side group Simon described how Mark became more sociable after the initial sessions when: Highlighted here is the way Mark's increasing sport competence resulted in social improvements. The important point is not so much that Mark was becoming more competent but that these publicly demonstrated achievements brought him recognition and attention from other group members. Through the performance of personally and socially valued skills Mark moved from being a quiet, unconfident, and anonymous member of the group to a person with the confidence to interact socially with others on an equal level. A further social change in Mark concerns his attitude toward others. In the context of the football group, Mark described a new awareness on his part of interpersonal relations and the subsequent satisfaction he gains from being a contributing member of the team: This excerpt suggests a change from a sole self-focus toward awareness and consideration of others in the immediate environment. It was Mark who captured the reasons for this change. Talking about his physical activity groups in general, Mark commented: "Well, you're meeting other people that are sharing a common thing, aren't you really? Common exercises. Sharing that experience, all doing the same thing, got the same experience and got something to talk about." It is in the context of an absence of shared activity during earlier periods of Mark's illness that the potential meaning and value of physical activity groups perhaps becomes clear. Sport and exercise groups provided Mark with a truly shared experience: something to talk about as well as an opportunity to talk. Mark described a range of benefits he perceives through diverse forms of sport and exercise. As he put it, "I enjoyed it, using the bike. It was a new experience for me 'cause I hadn't used the bike very much in the past so I enjoyed it." Likewise, "I feel healthier, more refreshed when I'm playing football," and he finds that exercise, "helps you to think better ... it helps you to concentrate better on what you're doing." While these benefits are undoubtedly important for Mark, it seems that they are in their place; physical activity is a complementary as opposed to a central component of Mark's life. In this regard, Mark's response to my question of whether exercise had made him a different person in any way is revealing: "No. It's not made me into a different person. I'm still Mark. But I feel a bit more energised, a bit more with it than I did before I started." For Mark, sport and exercise provides tangible, practical, day-to-day benefits, which contribute to rather than change his life. In this sense physical activity is just one aspect of Mark's life, no more and no less important than anything else that brings some kind of benefit. Regarding Mark's improving mental health, Simon believed: "I don't think, like with Colin, it [sport] is his main thing.... I think it's a combination of everything--not just his sport." A functional attitude is also reflected in Mark's inclusion of exercise in his daily schedule. Asked whether he thought about exercise prior to taking part in a session Mark replied: "No. I know I've got it on my agenda so I just wait until it comes round. I don't dwell on it.... [Then I] move on to something else--the next thing on the agenda." Reflections Faulkner and Biddle (2004) highlight "the fundamental importance of considering the wider context of participants' lives in order to understand the relationship between physical activity and psychological well-being" and suggest that "this relationship is likely to be complex and highly idiosyncratic" (p. 17). Through considering individual context in detail, the two case studies provide insights into the complex and idiosyncratic relationship between exercise and mental health. In the context of Colin and Mark's cases, this relationship is marked by both similarity and difference. Several similarities are evident in Colin and Mark's experiences. First, both describe an enthusiasm for sport and exercise as young people. As Brettschneider and Heim (1997) suggest, positive sport experiences at a young age increase the likelihood of sport participation in adult life. Second, both participants describe acute positive psychological benefits (such as "a lift," improved mood, improved concentration) through sport and exercise participation. These kinds of responses have been reported in other research with people with serious mental illness (Carless & Douglas, 2004; Faulkner & Sparkes, 1999; McDevitt et al., 2006) and also occur in the general population (Biddle, 2000). Third, in common with other research (Fogarty & Happell, 2005), both men describe social benefits in terms of shared experiences with others that provide something to talk about as well as an opportunity to talk. Raine, Truman, and Southerst (2002) report how these kinds of social opportunities were a critical component in the success of a community gym for people with mental illness. Fourth, opportunities for achievement and demonstration of personal competence through sport and exercise contexts are evident in both Colin and Mark's experiences. As Fox (1997) has suggested, these opportunities can be important in building physical self-worth, and even self-esteem, which is an important part of the recovery process (Deegan, 1996; Repper & Perkins, 2003). Finally, Martinsen (1995) and Fogarty and Happell (2005) highlight the way in which people with mental illness who engage in exercise tend to evaluate its contribution to their mental health in positive terms. It is clear in these case studies that both Colin and Mark valued sport and exercise highly; that it contributed to their lives in a positive manner. Also evident within the case studies is the way that "although commonalities exist, the personal weighting of motives and outcomes associated with exercise appear relatively unique and subject to variation" (Faulkner & Biddle, 2004, p. 15). Recovery, too, is characterised as a personal and subjective process that varies between individuals (Anthony, 1993; Coleman, 1999). In this sense, we suggest the variation and uniqueness inherent in the exercise-mental health relationship is important precisely because it allows individuals to experience different benefits appropriate to their own recovery needs. While both case studies shed light on how sport and exercise may contribute to the process of recovery through the development of new purpose and meaning in life and by facilitating the development of new attitudes, values, feelings, goals, skills and/or roles (Anthony, 1993), the way in which sport and exercise contributes to this process differs for Colin and Mark in ways we would now like to explore. A recurring theme in Colin's case is that sport is a central component of his identity--that Colin considered himself to be a sportsman. For example, Colin often wore sport clothing that signified his affiliation with sport (Schwalbe, 1993), he often used sport metaphors (describing for example how difficult life circumstances "knocked me for six"), and, in words and actions he revealed his interest, knowledge, and competence in sport. These factors contributed to David's initial impression of Colin as a person with an athletic identity (Brewer, Van Raalte, & Linder, 1993; Sparkes, 1998). Later, biographical objects (Dant, 2001) such as sporting memorabilia and photos confirmed the meaning sport held in Colin's life. A large social network in and through sport, combined with the ways in which sport and exercise allowed him to take control of aspects of his life, further support the important role sport and exercise play in Colin's life. Sparkes (1997) describes how "the problem of identity is the problem of arriving at a life story that makes sense (provides unity and purpose) within a sociohistorical matrix that embodies a much larger story" (p. 101). For Colin, maintaining his athletic identity became a problem when his involvement in sport was interrupted by the larger story of mental illness that resulted in sport and exercise disappearing from his life for several years. Sparkes further notes that, "As individuals construct past events and actions in personal narratives they engage in a dynamic process of claiming identities and constructing lives" (pp. 101-102). When Colin describes "getting back" to sport and exercise following the remission of his psychotic symptoms, we suggest he is reclaiming and reconstructing his sporting identity. In returning to sport and exercise, therefore, Colin achieves a sense of continuity and unity in his life story that gives him a sense of purpose despite the disruption caused by serious mental illness. It is this reclaiming of a coherent identity and, perhaps, his arrival at a sense of purpose that gets to the core of the role sport and exercise has played in Colin's progress toward recovery. Deegan (1996) argues that "because many of us have experienced our lives and dreams shattering in the wake of mental illness, one of the most essential challenges that faces us is to ask, who can I become and why should I say yes to life?" For Colin, sport and exercise provided an opportunity for him to begin to answer these questions. Being involved in sport and exercise was in itself a reason to "say yes to life" because being a sportsman is a defining characteristic of the person Colin wants to become or be. In contrast, Mark displayed no signs of sport or exercise being important aspects of his identity. Although Mark had a history of sport participation, his involvement ended when he left school. It wasn't until 18 years later that Mark engaged in sport or exercise and, tellingly, he described his activity as "starting afresh." Mark displayed no biographical markers linking his sense of self to sport: he did not wear sports clothing and owned no sporting equipment or memorabilia. Likewise, Mark rarely engaged in sport related conversations with other service users or mental health professionals. For Mark, rather than being a central, intrinsic component of identity, sport and exercise constitute forms of activity that bring about positive consequences or outcomes that hold value and meaning within his broader life context. Two consequences, we suggest, have been particularly important in Mark's case. First, Mark valued being able to take part in an activity that kept him busy. Other research (Faulkner & Biddle, 2004; McDevitt et al., 2006; Raine et al., 2002) has also identified keeping busy as a positive consequence of sport and exercise participation in mental health settings. For Mark, keeping busy took on a further dimension because he believed that by keeping busy with sport and exercise he was making positive use of his time; that he was engaging in a worthwhile activity. That sport and exercise are considered worthwhile by Mark relates to a second consequence of participation: perceived improvements in fitness. Thus, Mark attributed perceived fitness improvements to his sport and exercise participation, and these improvements better equipped him to meet the physical demands of his chosen vocational activities of gardening and woodwork. The kinds of fitness improvements Beebe and colleagues (2005) have also reported for people with serious mental illness allowed Mark to more fully engage in activities such as gardening and woodwork that hold personal meaning and value. It is these activities which, to use Deegan's (1996) terminology, represent the person he would like to become and, perhaps, provide him with a reason to "say yes to life." In this sense, as Raine et al. (2002) have also identified, sport and exercise have been more akin to a valuable tool or stepping-stone in Mark's recovery that helped him move on to other things. Closing Thoughts We suggest that understanding the distinct roles sport and exercise played for Colin and Mark will assist in the provision of personally meaningful sport and exercise opportunities for other men with serious mental illness. For men like Colin, for whom sport is central to identity and sense of self, sport holds intrinsic meaning and value and is worthwhile in its own right. The loss of sport opportunities through the experience of serious mental illness results in the denial of an essential aspect of self and the loss of opportunities to express and enact their athletic identity. By re-engaging in sport through activity provision in mental health settings, this valued aspect of self and identity may be recovered. These individuals, we suggest, are most likely to benefit from the provision of sport and exercise opportunities that closely match their personal interests. Their primary needs are likely to be encouragement and practical assistance to support the physical and psychological challenges associated with initiating sport and exercise participation after a potentially lengthy period of inactivity. In contrast, men like Mark use sport and exercise in an instrumental fashion--as a vehicle or tool that indirectly equips them to pursue other activities that hold personal meaning and value. 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Exercise interventions for mental health: A quantitative and qualitative review. Clinical Psychology-Science and Practice, 13(2), 179-193. U.S. Department of Health and Human Services. (n.d.). Retrieved 14 October 2006, from the World Wide Web: http://mentalhealth.samhsa.gov/features/hp2010/terminology.asp Wolcott, H. (2001). Writing up qualitative research. Thousand Oaks, CA: Sage. [1] Serious mental illness can be defined as "a diagnosable mental disorder found in persons aged 18 years and older that is so long lasting and severe that it seriously interferes with a person's ability to take part in major life activities." (U.S Department of Health and Human Services, n.d.). [2] Negative symptoms include blunted affect and low motivation. [3] Positive symptoms include hallucinations and delusions. [4] The Green Gym is an activity group for people with mental health problems that combines environmental education and activity such as forestry work with structured exercise. DAVID CARLESS Leeds Metropolitan University, UK KITRINA DOUGLAS University of Bristol, UK David Carless, Carnegie Research Institute, Leeds Metropolitan University; Kitrina Douglas, Department of Exercise, Nutrition and Health Sciences, University of Bristol. This research was made possible by the award of a postgraduate scholarship to the first author by the University of Bristol. We acknowledge and thank Ken Fox for his input during the early stages of the research and Margot Hodgson for her practical support. We would also like to thank Brett Smith, Samantha Holland, and the two anonymous reviewers for their constructive comments on earlier versions of this paper. Most importantly, we would like to thank Colin and Mark for sharing with us stories of their lives. Correspondence concerning this article should be addressed to David Carless, Leeds Metropolitan University, Carnegie Research Institute, Headingley Campus, Beckett Park, Leeds LS6 3QS, UK. Electronic mail: d.carless@leedsmet.ac.uk It is evident that the existing research does not allow any firm conclusions to be made as to the psychological benefits of exercise for individuals with schizophrenia. It does, however, support the efficacy of exercise in alleviating the negative symptoms [2] of schizophrenia and as a coping strategy for the positive symptoms. [3] (p. 453) Responses to exercise and preferred modalities are highly individualized, making it difficult to design programs for maximum appeal to the majority of persons. The disease of schizophrenia includes wide variability in baseline functioning, motivation, pharmacologic treatments and the like, which makes drawing conclusions across populations problematic. Clinical studies are further hampered by concerns over adequate diagnosis of schizophrenia and comorbid conditions that could affect exercise response. (Beebe et al., 2005, p. 673) Such limitations are implicitly recognised in the literature by the apparent dearth of material in comparison to the more "popular" and possibly less troublesome groups or participants such as those in nonclinical or "free-living" populations. This results in populations such as individuals with schizophrenia being silenced and marginalized by the pursuit of what are perceived to be safer and more familiar topics that rely on the use of an empirical methodology. (p. 54) Recovery is described as a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one's life, as one grows beyond the catastrophic effects of mental illness. (p. 19) I first started when I was young, 11,12, or 13 ... but I used to play football outside in the house gardens on my own, just kicking a ball, so really I started when I was about 7 or 8, I suppose.... I just thought it was a great game. I was just bored in there. Nothing to do.... I just stayed in the ward and just went to bed and that was it.... Just get up, have something to eat, a cup of tea, just sit in the television room, talk to somebody and then just hang about for a couple of hours unless a doctor wanted to see me.... I thought, well, I got nothing else to do.... I just want to go to sleep. Every other week we have a social group which is to try and normalise social activities ... very regularly we do some sort of sporting activity and we did outdoor bowls. We've done it twice and he is about the only person that can actually do it! All these bails that are, like, miles away from where they started! ... It's generally a really good laugh 'cause nobody can do it but he was really proud that he could. No, certainly not, quite the contrary. I'd say exercise has helped him cope with stresses and things. And he's got the backup of friends. He'll turn up at the football, cause he's had some financial difficulties that are probably the biggest stress that he's had, and chatting with the lads at the football about what to do about his credit card and things like that has helped him. So I'd say quite the contrary really. What's different about him is that he, more or less, he started doing the football and, more or less, most of the changes have been of his own volition. He's chosen to do those things rather than me saying, "Come on, I'll pick you up in the car, I'll take you there, I'll sort it all out for you," but he's actually run with the ball himself. That would be the most dramatic thing I think, that he's started to take control of his own life. The consultant came round ... to the house where I used to live and saw me a couple of times, come to my room, just say, "We're checking you out." ... And she said, "You gotta go to Brentree [hospital]--we're taking you in." The other main thing I think he's got out of it [sport and exercise] is the feeling that actually he could do something with his life. That actually he hasn't finished work, retired on the grounds of ill-health, and he's never going to work again. When he got involved in the green gym programme [4] he could start to see that doing volunteer work was something that he could quite easily do. I think that's opening up the bounds of possibilities for doing something, even working towards paid work in the end, and he has mentioned that to me once. So I think that's a big change, just thinking that he's got something--that his life hasn't ended, you know, he's got the illness, it's all over. Well, just the enthusiasm really. That's what has changed my life really. Well apart from the music I would say. If I didn't play football or have any music I don't think I'd be here today. I think it's kept me going. I had a chat with Sarah [a physiotherapist] when I was in woodwork and she suggested that I take up a bit of exercise to get a bit fitter. She said I wasn't very fit. So that's what I decided to do: decided to take up a bit of exercise, on the exercise bike. That's what I started on. And I progressed, one thing led to another, progressed to football, badminton and walking group. [H]e was very conscious he was making mistakes and didn't score or anything like that. Then he started being the top scorer 'cause he stood down the other end and kept hammering them in! Basically I think that was a day everybody noticed that, and focussed on that, and he achieved something.... When he was doing that I think he was a little bit more sociable after the game as well. Maybe, yeah, I'm sure he was, sort of came out a little bit more, a little bit more talkative. I get satisfaction from playing football. If I score a goal I'm pleased with myself and it gives satisfaction that way. Even if I didn't score a goal ... there's more to football than just scoring goals--you can get pleasure from playing good defensively or passing or helping out your fellow players.... I used to be a bit selfish and just go for goal all the time but I realised that you got other players in better positions. So I pass to them and hopefully they score.
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