A few months ago we were approached by the British Medical Journal’s online learning platform, ‘BMJ Learning’, to write a 30 minute training module to support talking therapists and health practitioners to introduce and discuss physical activity (PA) within therapeutic settings. This arose from practitioners’ identifying a need for guidance on how to introduce PA into sessions with people with depression, anxiety, and low mood, including people suffering with associated long term health conditions. BMJ Learning has over 1 million registered users around the world, so what an opportunity to share our learning of many years as a result of multiple trials and tribulations…
So what exactly was the challenge? Well, the National Institute for Health and Care Excellence (NICE) does have evidence-based guidelines regarding PA for the treatment and support of people with depression and/or anxiety. However, these guidelines have little consideration for their implementation – they are very much focussed on ‘efficacy’ (does it work under optimal conditions) rather than ‘effectiveness’ (how can/does it work in real life). The NICE guidelines for people with depression suggest a minimum of 1 supervised session per week of aerobic exercise for a minimum of 10 weeks in a group of around 8 participants, working towards at least 150 minutes of moderate activity per week. Whilst the biophysical and psychological mechanisms of PA and its impact on depression and anxiety are well established, it is not hard to see where the barriers for engaging in PA are for someone with depression and/or anxiety. Typified by low energy levels, poor sleep, rumination, low self-esteem and confidence, and a loss of any sense of control, competence, or connectedness – expecting someone to join a weekly supervised exercise class (even if it is available) will appeal to very few people, and this would normally happen separately to any talking therapy support. Our learning tells us things can be done very differently.
So, after several drafts, a film crew came down to Exmouth to record clips of Adrian (the more photogenic of us, and slightly nearer to their origins in Birmingham and London) highlighting the key messages behind the module. After an independent peer review by a clinical psychologist service lead, the module has been approved for publication. So what exactly has our learning taught us that that adds practical value beyond the NICE guidelines?
As a result of several large clinical trials, including ‘TREAD’ (treating depression with physical activity, where Tom was one of the practitioners, over 15 years ago), ‘BAcPAc’ (integrating PA into behavioural activation), ‘EARS’ and ‘TARS’ (looking to promote PA to help reduce smoking habits), and ‘STRENGTHEN’ (which included promoting PA to support mental wellbeing among people in the criminal justice system), we are confident in one thing – telling people what to do and prescribing PA for people facing complex situations simply does not work.
So at the heart of the module, is the patient. In order to integrate PA, it has to start with understanding the patient – their capabilities, opportunities, motivations and behaviours (the ‘COM-B’ model). We argue that NICE guidelines shouldn’t be introduced unless explicitly requested, as they may seem daunting, unobtainable, and therefore demotivating. Common to depression and low mood, people suffer from a loss of a sense of control, competence, and connectedness (low levels of self-determination). Prescribing something that is unobtainable can make all three of these worse. But when done well, PA can increase someone’s sense of control, competence, and connectedness and in turn support a sense of wellbeing, increased self-esteem, and confidence.
ANY change in PA should bring benefits, no matter how small. Like a snowball, a small 5 minute change in daily activities, whether that’s in routine, necessary, or pleasurable activities, can accumulate to provide great positive impact over time. Understanding people’s routines and starting with what someone feels confident to do and is important to them (e.g., doing the housework or some gardening, walking to the shops) is key. Understanding the patient and where they are and establishing some realistic and achievable goals (no matter how small!) is fundamental to introducing PA. For many people the word ‘exercise’ is unattractive and conjures up thoughts of a gym or a strenuous workout… (But of course these types of PA are beneficial should someone have the capability, opportunity, and motivation for it).
We draw on the principles of motivational interviewing as a way of ensuring discussions stay client centred and ‘owned’ by the patient, ensuring they stay in control of the decision making process (BMJ Learning has an introductory module to motivational interviewing techniques: https://new-learning.bmj.com/course/10051582). We highly recommend the module.
In a world of highly protocolised psychological therapy PA is seen by many practitioners as something other professionals offer. PA promotion can be easily integrated into both step 2 and 3 (moderate and high intensity talking therapies) without disrupting planned delivery. There is no need to prescribe or tell, and asking about PA a patient may have done in the past, or things they have stopped doing, can be a powerful way to introduce the idea. With skilful and client centred self-monitoring and goal setting, PA can feature in either Cognitive Behavioural Therapy or Behavioural Activation therapy if the talking therapist is interested in it and feels confident to promote it. The module aims to help practitioners to be interested and confident to bring PA into therapy. PA discussions are an important and additional tool, and by focusing on slow and safe progression even people with multiple chronic conditions can find ways to increase energy expenditure in a meaningful and satisfying way. The pilot BAcPAc trial 10 years ago in Devon showed (with extensive service user input) how to acceptably add PA into behavioural activation and the module draws on this study and subsequent client-centred interventions.
So we suggest, given the evidence, that PA discussions should be part of routine talking therapy as an extra tool for supporting positive change.
The module can be found here and is free to access: https://new-learning.bmj.com/course/10052400
It was a great opportunity to write this module, and we hope it can have a real impact for people working in some of the most challenging areas.