17.5: Motivation and Physical Activity

Physical inactivity is not just an issue for people with mental illness as many people in the Australian general population also do not meet the recommended guidelines for physical activity (150 minutes of moderate or 75 minutes of vigorous physical activity weekly; Australian Bureau of Statistics, 2015). In Australia, a little more than half of adults meet the guidelines for physical activity (Australian Institute of Health and Welfare, 2018). Less than half the population in the United States meet the recommended levels of physical activity (Carlson et al., 2015) and rates of inactivity are higher in Europe,where almost 60% of adults do not engage in appropriate levels of activity (Oja et al., 2010). Given the robust evidence demonstrating the benefits of physical activity in improving the physical and mental health of people living with severe mental illness, it is important to examine the ways in which people can be supported to engage in exercise throughout the life course. Examining people’s internal perceptions and motivation to exercise is a vital component of physical activity prescription (Chapman et al., 2016; Firth et al., 2016; Vancampfort, De Hert et al., 2015; Vancampfort et al., 2016).

Negative symptoms that are associated with schizophrenia can be associated with lower levels of motivation towards physical activity (Vancampfort, Stubbs, et al., 2015). These low levels of motivation may be related to a person’s own priorities towards exercise and their physical health, past experiences with engagement, or beliefs about structured physical activity. Competing interests and priorities including work, study, and family can also be factors that affect motivation, in addition to socioeconomic factors such as lack of access to resources (Ussher et al., 2007). Education about how to engage effectively and safely in structured exercise and fostering self-determined motivation through building self-confidence and a sense of competency can improve participation. People may have had previous negative experiences with exercise, which may affect future performance (Ladwig et al., 2018). The influences that may dissuade people with mental illness from engaging in physical activity should be discussed by their health care providers to formulate an exercise plan that is based on the person’s interests and preferences.

17.5.1. Self-Determination Theory

Examining the research into what motivates people to exercise is important for understanding how to support those with severe mental illness with long-term healthy behaviours (for more discussion on physical activity and exercise behavior, see Chapter 2 [Rebar et al., 2021], Chapter 4 [Brand & Ekkekakis, 2021], and Chapter 5 [Delli Paoli, 2021]). Utilising the self-determination theory (Deci et al., 2008)can be an effective way of facilitating long term enjoyment in physical activity (see Chapter 3;Quested et al., 2021). This theory is regularly used by many health professionals, including exercise specialists, to ascertain factors that guide someone’s motivation to engage in a particular behaviour (e.g.,exercise). It is applicable in the well-being and recovery of people with severe mental illness and can be used in the identification of external and internal forms of motivation. This theory examines specific basic psychological needs including autonomy, relatedness, and competence, and when applied to exercise can help people understand the reasons why they may or may not exercise. The theory states that intrinsic motivation is more conducive with exercise participation. Self-determination has been identified as important in people with schizophrenia for engaging in long-term exercise participation (Vancampfort, Stubbs, et al., 2015). So how does this work in practice? Motivational interviewing can be used with clients that have a mental illness to assist in promoting positive attitudes towards exercise and to help in discovering what motivates them to engage (Farholm & Sørensen, 2016).

17.5.2. Transtheoretical Model of Health Behaviour Change

The transtheoretical model (Table 17.2) suggests that making changes to health behaviours are typically achieved through five stages of change (Prochaska et al., 1997). These stages of change can assist in guiding conversation, education topics, and eventually exercise prescription (Prochaska et al., 1994).

Table 17.2. Stages of Change Based on the Transtheoretical Model

Stage	Stage Description
Pre-contemplation	During this period, people are not generally considering the practical steps to beginning exercise, so it is a good time to provide basic education. Identifying what is most important to them is of importance and gradually relating these goals back to the benefits of physical activity may be appropriate. As a clinician, you may then be able to get a level of understanding as to the client’s thoughts towards physical activity.
Contemplation	As a clinician you can use this time to provide more detailed education and challenge beliefs that the person may have about what participating in physical activity might look like. Motivational interviewing should continue.
Preparation	During this stage, the client should engage in goal setting around future planned physical activity, planning next steps, and exploring barriers and strategies to overcome challenges.
Action	The client should begin regular physical activity and ideally in an activity that is enjoyable to them. Work with your client to identify ways in which they might adhere to their schedule. These may include the use of activity trackers or finding a friend or partner to exercise with. Reflecting on past experiences can be helpful to manage mood and psychological states. Providing positive reinforcement should be a focus of the clinician. Working towards maintaining current physical activity levels should be a goal of this period. This includes increasing goal setting to long-term periods in addition to reviewing goals to overcoming obstacles to participation.
Maintenance	At this stage, the client should be able to maintain their current physical activity levels independently and identify what are the internal motivating factors to their participation. New activities can be introduced and a plan to return if lapses occur can be developed.

Throughout these stages, it is important to openly discuss and listen to the client’s needs and goals so that a recovery-focused approach to exercise prescription can occur (Slade, 2010). Understanding that symptoms of a person’s mental illness may mean that the process may not be linear, and flexibility may be necessary. It can often take multiple attempts before someone succeeds in adopting lifestyle changes for the long term and as such, these stages can often be cyclical in nature. These components should be key in the education provided to clients to manage expectations and assist the client in adherence to the physical activity program.

A typical approach of health professionals when educating people in lifestyle behavior change is to initially educate and then persuade them to adopt new behavior through prescriptive directions. However, this approach is not typically effective as the simple act of providing information does not result in long-term behavior change. Health coaching is a method of utilizing the motivational theories previously discussed (such as the self-determination theory and the transtheoretical model) and practically applying them in a real-world context (Table 17.3).

Table 17.3. Consider the Ways in Which People with Mental Illness Might Benefit from a Motivational Health Coaching Approach to Physical ActivityEducation Compared to a Traditional Model

Traditional Interviewing Style	Health Coaching
Clinician is the expert in health topic	Client is the expert in their own life experience and is respected to make autonomous decisions
Clinician give advice and prescribes solutions to solve problems	Client identifies areas of health they would like to work on, and clinician works through options available providing information as requested
Clinician decides that client is at the stage to make health changes	Client leads change and clinician uses strategies to increase client confidence and self-determination
Clinician focuses on why things are not being achieved and solutions to this	Clinician provides positive encouragement at whatever stage client is in

Learning Exercise Six

Imagine a person with schizophrenia has been referred to you for lifestyle intervention. Utilising the concepts of the self-determination theory, outline the key concepts of your interview and physical activity prescription, given the person is in the preparation phase of the transtheoretical model of health behaviour change.