Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Exercise Interventions for Mental Health and Addictions Populations: Exploring the CrossFit Gym Model

Victoria Houle

University of Ottawa

Fall/Winter 2017

Human Kinetics 4900

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

TABLE OF CONTENTS

Exercise Interventions in Mental Health Populations 3

Exercise Adherence in Special Populations 4

The Role of Social Support in Recreation 5

The Role of Social Support in the CrossFit Gym Model 6

Exploring the CrossFit Gym Model 7

Belonging and Inclusion in CrossFit 8

The CrossFit Gym Model and Self-Efficacy 10

Exercise and Affect: Barriers to Participation 10

Bibliography 11
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

It is well known that physical activity results in health benefits, however according to the 2016

Report on Canadian Health, only 20% of Canadian adults and 10% of Canadian children meet or exceed

the recommendation for physical activity, volume and intensity set out by the Canadian Physical Activity

and Sedentary Behaviour Guidelines for children and the Canadian Physical Activity Guidelines for

adults 18-64. In order to achieve optimal health benefits, adults aged 18-64 years are recommended to

accumulate at least 150 minutes of moderate- to vigorous-intensity aerobic physical activity per week, in

bouts of 10 minutes or more. Only 2 in 10 adults and 1 in 10 children met or exceeded the physical

activity guideline in 2013 (Canadian Physical Activity and Sedentary Behaviour Guideline). Along with

150 minutes of physical activity, the guidelines also recommend adults aged 18-64 add muscle and bone

strengthening activities using major muscle groups at least 2 days per week in order to reduce the risk of

premature death, heart disease, stroke, high blood pressure, certain types of cancer, type 2 diabetes,

osteoporosis, to avoid complications of being overweight including obesity, and to improve fitness,

strength and mental health such as feelings of morale and self-esteem (Canadian Physical Activity

Guideline). Why aren’t we getting enough? What do Canadians think about physical activity and how do

we encourage and include the most marginalized populations in need of health assistance in physical

activity programs and promote these groups to seek physical activity?

Exercise Interventions in Mental Health Populations

Several studies have found a significant relationship between increased physical activity and

decreases in anxiety and depression symptoms; one study found improvements in panic symptoms in an

exercise condition for individuals with agoraphobia (Wedekind et al. 2010), concluding that exercise had

a trend toward improvement compared with a ‘relaxation’ condition. Brown et al. (2007) used a sample

of 15 people and introduced an exercise intervention over 12 weeks consisting nof moderate intensity

aerobic activity 3-4 times a week, for 20-40 minutes, and found a reduction in Obsessive Compulsive

Disorder symptoms at post-treatment and again at 6 month follow up. Abrantes et al. (2009) also found a

reduction in obsessions at week 1 and week 12 of a 12 week program of aerobic activity (treadmill, bike,
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

elliptical) 3-4 times per week comprised of 20-40 minute sessions. Merom et. al (2008) used a larger

sample size (n = 41) of individuals with Generalized Anxiety Disorder, Seasonal Affective Disorder and

Panic Disorder, with two groups: one group participated in Cognitive Behavioural Therapy (CBT) and

psychoeducation, the other participated in both CBT and an exercise intervention (exercise performed at

home, e.g. home-based walking) for 8 weeks; researchers instructed participants to increase physical

activity up to 5 times per week, for 150 minutes total. Participants reported reduced depression, anxiety

and stress in the CBT and exercise group at post-treatment. Herring et al. (2012) also saw significant

reductions in worry symptoms in a study comprised of two exercise conditions: 1) resistance/weightlifting

training versus 2) aerobic/cycling exercise, compared to a control group, the 3) ‘waitlist’ condition,

however their exercise condition contained less physical activity than is recommended in the Canadian

Physical Activity Guideline: for the resistance/weightlifting intervention participants were led through

only 2 weekly sessions of lower body weightlifting, versus the second group performing an

aerobic/cycling activity 2 times weekly focusing strictly on cycling with the legs. The review of the

current literature begs the question: what improvements to mental health would we see with an exercise

intervention that follows the Canadian Physical Activity Guidelines, and how can we assist the most

vulnerable and marginal population in adhering to this exercise and being interested in a fitness program

in order to benefit from physical activity and achieve optimal health? Because “the environment in which

a sporting activity takes places has a tangible impact on the performance,” Heywood (2015, p. 1) future

research should explore the environment in which we participate in physical activity and its implications

for improving accessibility and inclusion for marginalized and special populations in order to give

everyone equal opportunity to receive the health benefits of physical activity.

Exercise Adherence in Special Populations

Strong research studies on factors contributing to exercise adherence in special populations and as

part of an intervention for mental health challenges yield different results depending on the research

design and are comprised of small sample sizes, however one notable study found a 50 per cent drop-out
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

rate for individuals joining a gym fitness program (Matsumoto & Tekenaka 2004). Research points to a

lack of self-efficacy, low body image, and poor time management as significant factors for determining

whether an individual sticks to a fitness program (Biddle et al., 2015). Other studies found that

participants described gyms as intimidating, and further alienating for participants, especially

marginalized groups suffering from depression or anxiety, and suggest that a decline in motivation stems

from avoidance of the experience because it does not offer many opportunities for social interaction

(Williams et al., 2007). Conversely, self-efficacy has been identified as a key psychological factor for

improving exercise adherence (Flora et al., 2015; Buckley, 2016; McAuley and Blissmer, 2000; Cooper et

al., 2015). Interestingly, self-efficacy is identified as a key factor for success in abstaining for drugs or

alcohol in substance abuse disorders and in recovery from mental health challenges (Brown et al. 2009;

McAuley and Blissmer, 2000). Exploring alternate gym models that focus on avoiding negative feelings

which hamper exercise adherence leading special populations to discontinue their health and fitness

programs due to feeling intimidated by exploring an alternative a gym model that focuses on eliminating

lack of social interaction, poor body image, while also increasing feelings of self-efficacy, is an important

consideration for future research.

The Role of Social Support in Recreation

The current research suggests that feelings of social support are important for exercise adherence

in a society that is in desperate need of increasing frequency and volume of physical activity of our most

vulnerable and marginalized populations. According to Fenton et al. (2017), individuals with mental

illness are more disabled by the social implications of their illness (e.g. stigma, social exclusion) than by

the symptoms themselves (p. 12). Several studies have looked at the role of social inclusion on recovery

for populations facing mental health challenges, pointing to hope, empowerment, and self-determination

as some of the potential benefits individuals gain when engaged in recreation programs. Recovery has

been shown to be supported through increased self-esteem, self-confidence, expansion of individual social

networks and feelings of social inclusion (Fenton et al., 8). Fenton et al. (2017) completed a review of the
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

current literature on recreation programs and their positive benefits on populations with mental health

challenges, with the most notable positive effects being reduced stress, improved quality of life and life

satisfaction and increased self-esteem. Fenton (2017) evaluated which psychological constructs improved

out of all the studies reviewed and found many reported sense of accomplishment (34.3%), increased self-

confidence (34.3%), increased ability to cope (25.7%), improved physical health (22.9%), improved sleep

(11.4%), increased energy (8.6%), weight management (8.6%), improvement in concentration (5.7%),

better mood and management of condition (22.9%), decreases in hospitalization (22.9%), skill

development (22.9%) and finally, seeing these benefits of the recreation activity spilling into other areas

of life (14.2%). Some of the attributes the authors saw as being essential to successful recreation

programs for populations with mental health challenges included: a nonjudgmental atmosphere that is

emotionally safe, activities that encourage socialization, discussion of shared experiences, developing

camaraderie, flexibility of choice, learning practical skills, and engaging inclusive style, comfortable

atmosphere (Fenton et al. 2017). All of the activities mentioned in the review support recovery by

highlighting the value of attaining pleasure by providing immediate gratification, but also increasing

‘personal capital’, including physical, intellectual, social, and psychological resources. In addition, the

authors argued that the value of engagement in community-based recreation is a powerful way to support

recovery, especially a supportive environment that fosters the creation of social connections.

The Role of Social Support in the CrossFit Gym Model

In Addiction, Recovery and CrossFit published in the CrossFit Journal in 2012, Ron Gellis, a

recovering alcoholic and psychologist, speaks of a program he developed that combines elements of the

traditional 12-step program with the CrossFit gym model. CrossFit differs from the tradition gym model0

whereby a group of people perform the same workout together scaled to their individual fitness level by

the direction of one or two coaches, surrounded by other people who share the same goals, in mutual

interest of each other’s progress. “One of the things that struck me immediately was the strength of the

community in CrossFit,” says Gellis, “and in dealing with addictions, one of the biggest problems is the
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

isolation that people have. So anything that speaks of community support is a good thing.” Recent on the

CrossFit gym model versus tradition gym models found that members of CrossFit gyms reported higher

levels of social capital on both bridging and bonding subscales and significantly higher levels of

community belongingness (Whiteman-Sandland et al. 2016, 3).

Exploring the CrossFit Gym Model

The CrossFit gym model consists of doing several exercises based on functional movements.

CrossFit gyms operate in one hour time slots and members exercise as a group. A group of 5-20 people

are supervised by a certified CrossFit Coach, while they complete one workout together at the same time

(called the ‘Workout of the Day’, or WOD) which is completely scaled to their individual abilities.

Coaches discuss scaling options with the group and with each member before the workout commences.

CrossFit’s aim is to shape different features of physical fitness – endurance, strength, speed, coordination

or power (Murawska-Cialowicz, 2015). A recent study found that after 3 months of participating in

CrossFit saw a reduction in adipose tissue percentage, improvement in aerobic capacity and increase in

lean body mass. Participants also saw increases in the efficiency of energy processes, cardiovascular

fitness, improvement in nerve-muscle coordination, and improved cognitive function (Murawska-

Cialowicz, 2015). In addition, participants saw increased tolerance of fatigue, faster restitution, improved

short-term memory, and improved maintenance of long-term potentiation (LTP), (Murawska-Cialowicz,

2015).

CrossFit gyms are by nature based on social interaction, where members exercise together and

cheer each other on regardless of their fitness level. Members are able to identify with other members and

strengthen a general ‘community’ environment. One study adapted Social Capital and General

Belongingness scales to compare perceptions of traditional gyms versus CrossFit Gyms (Whiteman-

Sandland et al. 2016) and found that enhancing the social environment through the emphasis on group

exercising has a positive effect on exercise adherence. Because social inclusion and exercise adherence
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

were found to be important factors for engaging marginalized and vulnerable populations in physical

activity not only for recovery but for optimal overall health, it is a gym model worth exploring.

Belonging and Inclusion in CrossFit

Whiteman-Sandland et al. argue that the CrossFit gym model gives members “a sense of

meaning, purpose and affiliation”, and a “greater opportunity for diverse social networking”, and is by

nature an environment more open to social interaction and feelings of social identity - individuals achieve

goals together, assisted, validated, and celebrated by their peers (Walton et al. 2012). By belonging to a

group, members are able to participate in and learn from other members, model and practice adaptive

health behaviours (Dowd et al., 2014) and an increased sense of self, which is supported by the social

identity theory: when people identify with a group, they are more likely to place greater value on behavior

modeled in the group (Burns et al, 2012), keeping participants engaged and coming back.

The ‘power’ of groups, social capital, and learning adaptive health behaviours in recreation

programs are discussed in the current therapeutic recreation research designed for groups with mental

health challenges (Fenton et al. 2017). Further, it is the power of social inclusion that is also credited for

being a healing property of 12-step groups (e.g. Alcoholic Anonymous and Al-Anon Family groups, and

emerging alternatives such as SMART recovery) for individuals recovering from drug and alcoholic

addiction (Zemore, Kasukatas et al 2016). According to Degenhardt and Hall (2012), illicit drug use

claims the lives of approximately 250,000 people each year worldwide, and 2.25 million deaths each year

are attributed to alcohol abuse. For over twenty years, exercise has been promoted by clinicians caring for

individuals struggling with addictions and mental health challenges because it is intrinsically rewarding,

engaging, and for many individuals with maladaptive behaviours, it is a safe and healthy alternative

adaptive behaviour (Linke & Ussher, 2017, 8). Unfortunately, addiction treatment programs rarely

incorporate dedicated time for exercise, or they primarily utilize the aerobic system, and do not meet the

Canadian Physical Activity Guidelines.

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Exercise Interventions for Mental Health and Addictions Populations

Linke and Ussher (2017) found that most of the current research on addictions populations and

exercise interventions utilize small sample sizes, uncontrolled study designs, with low exercise adherence

and inadequate methods of measurement, as well as insufficient exercise frequency or volume. A recent

review by Giesen, Diemel and Bloch (2015) did find that exercise interventions are a promising

complementary treatment component for addictions populations and find that exercise has an important

role in the regulation of emotions such as depressiveness, anxiety, tension and stress, sleep disturbances

and other psychological outcomes - emotional states that have been linked to relapse. The review found

that exercise has also been shown to regulate substance-specific outcomes such as craving for alcohol or

cigarettes (Giesen et al., 2015, 1). Brown et al. (2014) suggests that physical activity has a positive impact

on drinking behavior in alcoholics. With the current evidence supporting that exercise has a positive

impact on the prevention and treatment of substance use disorders, it is important to explore the CrossFit

gym model further as a recreation program with physical health benefits and psychological benefits with

the added benefit of being a supervised program within a larger supportive community environment that

is socially inclusive for a population struggling with mental health challenges, including marginalized

populations struggling with addictions. Linke and Ussher (2017) conclude that there is a need for

improved strategies for measuring outcomes, and new techniques to improve adherence to exercise

programs. The CrossFit gym model advocates ‘constant variation’ and CrossFit gyms make use of

equipment and exercises from multiple sports: Olympic lifting, power lifting, running, rowing,

plyometrics, gymnastics, Strongman, swimming, and several others (Heywood, 2015, 24). Each workout

is specifically programmed daily, and each workout is progressive and periodized (Heywood, 2015, 25).

It is the principle of ‘scalability’ that makes the CrossFit gym model suitable for special populations:

meaning that each movement, each piece of the workout, can be scaled to be easier or harder for each

individual in the larger group exercising together. The CrossFit gym model should also be considered for

future research because unlike other exercise interventions discussed in the current research, it is
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

comprised of timed workouts and an existing system of measurement, and the workouts are consistent

with the volume and intensity recommended by the Canadian Activity Guidelines. Also importantly,

CrossFit is a supportive recreation program comprised of physical activity at high intensity in a

supportive communal context. According to Heywood (2015, 25) “in a neuropsychological sense, the

community context provides a sense of safety that triggers…the Social Engagement System

(SES)…completing physical tasks and bonding with the group. This group is then connected virtually to

CrossFitters worldwide across a variety of social media platforms.” In this way, CrossFit becomes not

only a way to benefit from individualized and supervised physical activity, but also as a “bonding

mechanism for groups sometimes otherwise marginalized within physical culture,” such as gender, those

stigmatized by sexual orientation, race, age, physical appearance, mental illness, or addictions.

The CrossFit Gym Model and Self-Efficacy

Strong self-efficacy has been identified as a strong indicator for attaining and maintaining abstinence

from substance abuse (Linke and Ussher 2017, pg. 9) The CrossFit model avoids threats to self-efficacy

found in competitive sports because it is a participatory model of sport, where “there are no threats to an

individuals’ status within a prestige hierarchy” and further, the CrossFit sport differs from other

competitive sports because it is “a non-instrumental activity done for itself, not as a means to an end/goal”

(Heywood, 2015, p. 26). In other words, it “is performed in the context of safety, not threat/humiliation”

which is why it is model worth exploring to promote “in-group bonding” and “empowerment of

disenfranchised individuals or groups” (p. 26).

Exercise and Affect: Barriers to Participation

According to Heywood (2015), “affect foreshadows every event” (p. 23) and this extends to

recreation and leisure. Current research shows that considering affect is important for engaging

participants in physical activity programs by providing personal fulfillment, meaningful engagement and

overall well-being (Fenton et al., 2017). Fenton et. al (2017)’s review identified several internal barriers
Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

interfering with participation in recreation programs (Carter-Morris & Faulkner, 2003), calling for the

need to focus on creating accessible and inclusive community spaces. Unlike traditional competitive

sports, CrossFit allows the participant to see his or her participation in daily workouts “as an immersion

that is something larger than attaining victory on a particular day” (Heywood, 2015, 21). CrossFit gives

members the ability to develop personally meaningful relationships and fosters social inclusion, which in

turn leads to increased access to community and community resources and as such, CrossFit can be seen

as a metaphor for “a bridge into the community” (Fenton et al., 2017).

Exploring the CrossFit gym model in future research in contrast and comparison to the traditional

gym model in engaging marginalized and special populations will determine whether there is improved

adherence to exercise interventions for substance use disorder treatment. Future research should also

focus on designing interventions that center on social connection, self-efficacy, bridging and bonding.

Another focal point of future research could be designing and implementing exercise interventions that

concentrate on building and maintaining positive affect in participants in the exercise environment.

Exercise interventions that are progressive and periodized and either embrace or are comprised of a

system of measurement like the CrossFit gym model should also b e explored. Exercise interventions in

future research should use principles of scalability and include supervision, and focus on improving

accessibility and inclusion for marginalized and special populations so that everyone can benefit from

physical activity as set out by the Canadian Physical Activity Guidelines.

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Bibliography

Abrantes, A.M., Strong, D.R., Cohn, A., et al. (2009). Acute changes in obsessions and compulsions

following moderate-intensity aerobic exercise among patients with obsessive-compulsive

disorder. Journal of Anxiety Disorders. (223), 923-927.

Bartles, S. J., Pratt, S. I. Aschbrennet, K. A., Barre, L. K., Jue, K., Wolfe, R. S., . . . Muser, K. T. (2013).

Clinically significant improved fitness and weight loss among overweight persons with serious

mental illness. Psychiatric Services, 64(8), 729-736

Biddle, S.J. H., Mutrie, N., and Gorley, T. (2015) Psychology of Physical Activity: Detriments, Well-

being and Interventions (3rd edition). London: Routledge

Brown, R. A., Abrantes, A. M., Read, J. P., Marcus, B. H., Jakicic, J., Strong, D. R., Oakley, J. R., et al.

(2010). A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Mental

Health and Physical Activity. 3(27), 27-34.

Brown, R. A., Abrantes, A. M., Read, J. P., Marcus, B. H., Jakicic, J., Strong, D. R., Oakley, J. R., et al.

(2009). Aerobic exercise for alcohol recovery. Behavior Modification. (33), 220-249.

Brown, R. A., Abrantes, A. M., Strong, D. R. et al. (2007). A pilot study of moderate-intensity aerobic

exercise for obsessive-compulsive disorder. Journal of Nervous and Mental Disease. (195), 514-

520

Buckley, J. (2016). Exercise self-efficacy intervention in overweight and obese women. Journal of Health

Psychology. (21), 1074-1084

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Burns, G. N., Jasinski, D., Dunn, S. C., et al. (2012). Athlete identity and athlete satisfaction: The

nonconformity of exclusivity. Personality and Individual Differences. 52(3), 280-284

Burton, J., Griffin, M., & Pretty, J. (2012). Exercise-, nature- and socially interactive-based initiatives

improve mood and self-esteem in the clinical population. Perspectives in Public Health, 132(2),

89-96

Canadian Physical Activity and Sedentary Behaviour Guidelines. Retrieved March 13th 2017,

http://www.csep.ca/cmfiles/guidelines/csep_guidelines_handbook.pdf

Canadian Physical Activity Guidelines. Retrieved March 13th 2017.

http://csep.ca/CMFiles/Guidelines/CSEP_PAGuidelines_adults_en.pdf

Degenhardt, L. and Hall, W. (2012). Extent of illicit drug use and dependence, and their contribution to

the global burden of disease. The Lancet 2012. (379), 55-70

DeHerdt, A. Knapen, J., Vancampfort, D., DeHert, M., Brunner, E., & Probst, M. (2013) Social anxiety in

physical activity participation in patients with mental illness: A cross-sectional multicenter study.

Depression and Anxiety, 30(8), 757-762, doi:10.1002/da.22059

Dowd, A.J., Schmader, T. and Sylvester, B. D., et al. (2014). Effects of social belonging and task framing

on exercise cognitions and behavior. Journal of Sport and Exercise Psychology. 36(1), 80-92

Elime, R. M. Young, J. A., Harvey, J. T., Charity, M. J., & Payne, W.R. (2013). A systematic review of

the psychological and social benefits of participation in sport for adults: Informing development of a

conceptual model of health through sport (Research Report). The International Journal of Behavioral

Nutrition and Physical Activity, 10, 135.

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Flora, P. K., Brawley, L., Sessford, J. D., et al. (2015) Predicting planned physical activity of individuals

with arthritis: A self-regulatory perspective. Journal of Health Psychology. 1-11

Herring, M.P., Jacob, M.L., Suveg, C., Dishman, R.K., O’Connor, P.J. (2012). Feasibility of exercise

training for the short-term treatment of generalized anxiety disorder. Psychotherapy and

Psychosomatics. (81), 21-28

Heywood, Leslie. (2015). The CrossFit Sensorium: Visuality, Affect and Immersive Sport. Edinburgh

University Press. (38)1, 20-36

Iwaska, Y., Coyle, C., Shank, J.W., Messina, E., Porter, H., Saltzer, M. . . . Koons, G. (2014) Role of

leisure in recovery from mental illness. American Journal of Psychiatric Rehabilitation, 17(2),

147-165

Matsumoto, H., and Tekenaka, K. (2004). Motivational profiles and stages of exercise behavior change.

International Journal of Sport and Health Science (2), 89-96

McAuley, E. and Blissmer, B. (2000). Self-efficacy determinants and consequences of physical activity.

Exercise and Sport Sciences Review. 28(2), 85-88

Merom, D., Phongsavan, P., Wagner, R. et al. (2008). Promoting walking as adjunct intervention to group

cognitive behavioural therapy for anxiety disorders – a pilot group randomized trial. Journal of

Anxiety Disorders. (222), 959-968

Wedekind, D., Broocks, A., Weiss, N., Engel, K., Neubert, K., Bandelow, B. (2010). A randomized

controlled trial of aerobic exercise in combination with paroxetine in the treatment of panic

disorder. World Journal of Biological Psychiatry. (11), 904-913

Running head: EXERCISE INTERVENTIONS FOR MENTAL HEALTH AND ADDICTIONS POPULATIONS

Whiteman-Sandland, J., Hawkins, J. and Clayton, D. (2016). The role of social capital and community

belongingness to exercise adherence: An exploratory study of the CrossFit gym model. Journal of

Health Psychology, 1-12

Williams, N. H., Hendry, M., France, B., et al. (2007). Effectiveness of exercise-referral schemes to

promote physical activity in adults: A systematic review. British Journal of General Practice.

57(545), 979-986

Zemore, S. E., Kasukatas, L. A., Mericle, A., Hemberg, J. (2016). Comparison of 12-step groups to

mutual health alternatives for AUD in a large, national study: Differences in membership

characteristics and group participation, cohesion, and satisfaction. Journal of Substance Abuse

and Treatment. 73, 16-26