Health disparities facing people served by the public mental health system are well known and remain a significant concern. In the 1990s, following recognition a 15-year loss of life for people served by the public mental health system, Peggy Swarbrick, formalized a holistic wellness dimension model (eight overall dimensions and six physical domains) to help people remember to view themselves holistically, as mind, body, and spirit. When we learned that the early mortality figures can be as high as 25-32-year loss of life in some states, we organized a series of projects and workforce initiatives to help mobilize and prepare the workforce to assist effectively and act proactively. Here, we highlight some efforts we have spearheaded: defining wellness, health and wellness screenings, wellness coaching, health literacy, and health and wellness self-care resources.
Wellness is a conscious, deliberate process that requires a person to become aware of and make choices that help promote a more satisfying lifestyle. A wellness lifestyle includes a balance of health habits, such as adequate rest and sleep, good nutrition, exercise, productivity, participation in meaningful activity, and seeking social contact and supportive relationships (Swarbrick, 1997). Unfortunately, many people encounter physical, emotional, and social challenges that impact their well-being. Modifiable lifestyle factors, including smoking, poor nutrition, poor access to quality healthcare, and a sedentary lifestyle, often contribute to preventable illnesses, diseases, and premature mortality. The eight dimensions of wellness are physical occupational social emotional, intellectual, environmental, financial and spiritual. This dimensional model has been adopted by the SAMSHA Wellness Campaign.
Health and Wellness Screenings
In 2009, Peggy and her colleagues at Collaborative Support Programs of New Jersey began to help organize health screenings at large conferences in New Jersey and at the national Alternatives Conference. We were pleasantly surprised to see how many people were interested in learning about their blood pressure, glucose levels, and other risk factors for diabetes and cardiovascular disease. We mobilized and trained peers interested in health and wellness to be available to conduct such screenings. We then worked with the UIC Center on Psychiatric Disability and Co-Occurring Medical Conditions to create a new integrated health tool called, Promoting Wellness for People in Mental Health Recovery: A Step-by-Step Guide to Planning and Conducting a Successful Health Fair. Health fairs help people in mental health recovery better manage medical conditions that can be improved with screening, education, and support. Health fairs also help people learn about their health and support them in making choices that lead to a satisfying lifestyle. From this study is a new publication (Swarbrick et al., 2013), highlighting peers’ unique perspectives about how health fairs motivated them to take steps towards a healthier lifestyle.
Given the large contribution of lifestyle factors to early mortality (Schroeder, 2007), interventions focused on lifestyle modification are key to addressing existing health disparities. One such intervention is wellness coaching, which offers support to regain balance and restore wellness.
The wellness coach model is an approach that can be helpful for someone who wants to make a lifestyle change (anything from smoking cessation, to exercise, to career exploration, to relationship building) or for someone who needs support in managing a chronic health condition, such as diabetes, metabolic syndrome, a mental illness, arthritis, or fibromyalgia. Wellness coaching is based on the premise that individuals can learn to promote their own health, contributing to the self-management of their health and/or illnesses. Wellness coaches apply principles and processes of professional life coaching to the goal of lifestyle improvement (Swarbrick et al., 2008).
Wellness coaches are trained to apply health promotion strategies through education, guidance, and support, designed to promote successful, positive, and durable behavior change. The aim is to empower the person seeking change to assume responsibility for his or her own individual, healthy lifestyle patterns. The wellness coach helps a person to set and achieve a wellness or health goal by offering support and encouragement and by exploring what would be most helpful. Coaching is not counseling or therapy; therefore a coach is not a therapist, counselor, or mentor. Coaching does not require that a person explore his or her past experiences nor gain insight into problems or challenges encountered. A coach does not provide a prescription, wisdom, or advice, but rather helps the person seeking coaching to define what is important and to set a plan to accomplish a personally valued goal.
Coaching is a positive supportive relationship between the coach and the person who wants to make a change. This positive supportive connection empowers the person seeking change to draw upon his or her own abilities and potentials to achieve lasting lifestyle changes. A critical aspect of coaching is self-responsibility. Through coaching, people can determine what they are responsible for and become empowered to take action to improve their wellness status, in terms of the many dimensions of wellness: spiritual, emotional, physical, environmental, intellectual, financial, occupational, and social.
CSPNJ, in collaboration with Rutgers University, has offered wellness coaching training in multiple states to peer workers, case managers, nurses, and supported housing workers. Training requires a significant investment, four to five full days, and extended follow-up, ideally for at least six months. The best success implementing the wellness coaching model occurs when agencies train and support administrators and supervisors as well as direct care staff, and conduct agency-wide campaigns to infuse wellness into the agency culture.
One barrier to improving physical health through mental health services is that direct service providers often lack knowledge about common medical conditions, interpretation of lab values, the importance of regular screenings, and basic disease management strategies.
Health literacy training helps frontline staff feel prepared to address the health disparities facing persons served. Typically, training content focuses on the areas of health literacy, physical health and wellness, and motivational enhancement techniques to engage persons served in health dialogues and, ultimately, health behavior improvement. Staff learn about common health issues and risks and how they are best addressed, including, but not limited to, pulmonary conditions, metabolic syndrome, cardiovascular disease, diabetes, obesity, and tobacco use. Staff increase their awareness of how and why health literacy and motivational strategies can improve quality of life. We have worked with agencies in two states and are beginning to see a positive impact.
As with wellness coach training, health literacy training needs to be followed by time-limited technical support mentoring phone sessions, designed to help staff apply skills and information in their day to day encounters with persons served. On the calls, staff actively engage in team problem solving and began to compile health information they could consider using with the people they serve. We have found the training and technical support process increases staff comfort in addressing health issues over time, and increases their confidence and proficiency applying heath literacy skills. In one training project, a notable outcome was that every person served who was invited to participate in the pilot completed the project. This is significant, as many of these individuals encountered challenges that may have led to dropout.
In one training project, the entire team is now placing attention to persons served needs in a very holistic manner, despite implementation challenges. At times, the immediate crisis (potential loss of housing, exacerbation of psychiatric symptoms, substance use relapse, etc.) impact the efforts of the person served and temporarily limited progress. However, staff remained supportive and attentive throughout to be sure physical health needs were supported equally to maintain focus and balance. Staff did an excellent job engaging people who had not been following up with important doctor /medical appointments. In addition, staff worked to empower persons served to work with their pharmacists. Staff developed a trusting rapport with persons served, which helped them consider important health issues to improve or change.
In addition to engaging persons served through daily or weekly outreach, staff were able to connect with and link people to local community resources (local parks, gyms, etc). Some other notable outcomes include:
- Decreased use of emergency room use for physical health problems, increased interested in smoking cessation, and increased involvement in physical activities.
- Mental health symptoms were less impacted by physical health problems.
- Many individuals are following up with primary care providers and medical specialists. Many are participating on groups addressing addiction issues, enhancing community and social awareness. According to staff reports, persons served have developed a proactive attitude towards health/wellness, as evident in the number of times certain individuals are now meeting with primary care physical and other specialists. In the past some individuals would not regularly follow up with appointments and disregarded serious health symptoms are now regularly attending appointments and following up with health routines.
- Some persons served are using harm reduction strategies for smoking cessation.
- Some individuals are increasing accessing to social support (including sponsor, reconnecting with family for the holiday).
Health literacy training has been conducted at two large community based psychosocial agencies and it is a key component of the wellness coaching training.
Wellness Self-Care Resources
Because each person defines wellness in his or her own way and has different risks, needs, strengths, concerns, and preferences, we have created self-care resources available for people in recovery and their supporters. Our all-time “reader favorite” document is the 24-page Wellness in Eight Dimensions. Each dimension is defined, includes an opportunity for the reader to assess and score strengths, suggests ways to focus on wellness, and provides space to identify relevant personal goals. An 18-page Physical Wellness booklet is organized into six physical wellness domains: (1) Physical Activity, (2) Sleep/Rest, (3) Relaxation/Stress Management, (4) Eating Well, (5) Habits & Routines, and (6) Screenings. This booklet provides definitions for each domain, a self-assessment, and a space to identify wellness goals and next steps.
Not only have these and other resources been used effectively by individuals on their own, they have been used in peer run and traditional community and hospital programs that run wellness-related groups. Given the limits of current availability of staff training in health and wellness, such resources provide an opportunity for learning as well as guidance for beginning the important conversations that will help address poor health, health risks, and the abbreviated lives experienced by people in the publicly funded mental health system.
We are passionate and committed to improve the lifespan and quality of life among people served by the public mental health system. We hope these training efforts and resources can empower the workforce to share our passion and commitment.
Peggy Swarbrick, PhD, FAOTA works for the Collaborative Support Programs of New Jersey (CSPNJ) Wellness Institute and is a part time Clinical Associate Professors at Rutgers School of Health-Related Professions (SHRP) Department of Psychiatric Rehabilitation and Counseling Professions. She can be contacted at firstname.lastname@example.org.
Pat Nemec is an independent trainer and consultant in psychiatric rehabilitation. She has an appointment as an Adjunct Associate Professor at Rutgers University (SHRP) and collaborates with CSPNJ on a number of wellness-related projects. She can be contacted through her website at www.patnemec.com.
- Promoting Wellness for People in Mental Health Recovery: A Step-by-Step Guide to Planning and Conducting a Successful Health Fair, http://www.cmhsrp.uic.edu/health/designing_health_screening.asp.
- Wellness in the 8 dimensions and other wellness booklets, http://www.cspnj.org (go to articles, then wellness resources; scroll through “older entries”)
- SAMHSA Wellness Campaign, http://www.promoteacceptance.samhsa.gov/10by10/wellness_tools.aspx
Schroeder, S. (2007). We can do better—Improving the health of the American people. New England Journal of Medicine, 357, 1221-1228.
Swarbrick, M. (1997). A wellness model for clients. Mental Health Special Interest Section Quarterly, 20, 1-4.
Swarbrick, M. A., Cook, J., Razzano, L., Yudof, J., Cohn, J., Fitzgerald, C., Redman, B., Costa, M., Carter, T., Burke, K., & Yost, C. (2013). Health screening dialogues. Journal of Psychosocial Nursing and Mental Health Services, 51(12), 22-28. doi: 10.3928/02793695-20130930-02
Swarbrick, M., Hutchinson, D., & Gill, K. (2008). The quest for optimal health: Can education and training cure what ails us? International Journal of Mental Health, 37(2), 69-88.