When I began working as a case manager at a supportive housing site for formerly homeless adults with mental illness in East Harlem, I quickly noticed that the large majority of tenants experienced a preventable physical health problem related to obesity. I later learned that their endemic deconditioning reflects broader social trends. In fact, individuals with serious mental illness die, on average, 25 years earlier than the general population. These premature deaths do not result from some quirk of brain chemistry. Instead, the majority stem from preventable health conditions such as cardiovascular disease, diabetes and respiratory problems. Poor nutrition, cigarette smoking, obesity and lack of exercise -- risk factors associated with poverty -- contribute to and exacerbate those maladies.
Gradually, I noticed a frequent gap in my clients' treatment. Although physicians would instruct obese individuals to "lose weight," the directive often fell flat when the individual lacked exercise education or experience. At times, the warning created an additional stressor that exacerbated anxiety and other mental health issues.
See the pattern? Poverty, mental illness and poor physical health weave a lethal web that can ensnare an individual and prompt premature death (not to mention exorbitant medical spending). Individuals like my clients deserve integrated programs that empower them to set specific health goals and then achieve those goals through supervised, tailored exercise programs in collaboration with traditional clinical service providers like social workers and case managers.
In New York City, where roughly 20 percent of residents experience mental illness and where nearly 2 million people live in poverty, a few social service agencies have confronted the challenge by committing to programs that fuse fitness with mental health. Last summer, I began working as a fitness consultant for Lantern Community Services, a supportive housing organization for formerly homeless adults with sites throughout New York City. In this capacity, I facilitate fitness programs and train tenants at gyms that Lantern built within its residences. Fountain House, an agency that follows the clubhouse model, empowers its individuals with mental illness by partnering with them to run employment, education and wellness programs, which they call units. Fountain House features a gym and encourages exercise as part of its comprehensive perspective on health.
Fountain House Wellness Unit Director Joe Shaffer acknowledged that almost all individuals, including people without mental illness, have issues maintaining healthy lifestyles, but, he explained, mental illness poses an added burden.
"When you're working with a population where some of the negative symptoms of their illnesses are a lack of motivation and they're dealing with side effects of the medications that are helping with their mental health [but] stand as an additional obstacle to leading a physically healthy life, these are things you have to address and acknowledge and [thus] incorporate more healthy services into their life," Shaffer said.
Shaffer explained that research into premature death among people with mental illness motivated Fountain House to develop stronger exercise and nutrition initiatives. The mission became more urgent when several of the organization's members died of preventable illnesses, he said.
Crucially, the fitness program enables individuals to practice skills and healthy behaviors that they translate into broader society.
"Our goal is not to keep members within this safe bubble of Fountain House and only help them to be well here," Shaffer said. "It's to provide them with support, structure, framework, confidence and a knowledge-base to be able to put that into practice within the greater community.
La Palestra, a company that operates several premium gyms around New York City, champions a similarly integrated approach to mental and physical health for wealthier individuals. The company, founded by trainer Pat Manocchia in 1993, serves as a model for holistic, preventive health care because its members meet with an in-house team of personal trainers, specialized physicians, nutritionists, psychiatrists and social workers who work together to coordinate care.
"When you're creating a health program for someone, you have to deal with the entire individual specifically because your health is in behavior," Manocchia said. "[Health] is not something that just happens to you. Your diet is behavior. Your exercise patterns are behaviors. Lifestyle is behavior."
Manocchia said he was inspired to address the intersection of mental and physical health when one of his clients refused to look at herself in a mirror despite her significant postural imbalance. He said he reached out to a psychiatrist, whom he also trained, for advice on engaging the woman.
In 2009, Manocchia and his wife Deborah, a licensed social worker, developed a non-profit organization called La Palestra Kids based on their holistic health approach. The organization serves children and their parents in East Harlem and stands out in its effort to translate integrative health programs to low-income individuals at high risk for developing preventable illnesses.
Fortunately, policymakers have begun paying attention to the interconnectivity among physical health, mental health and social risk factors. In March, the Obama Administration announced a proposal to fund "lifestyle change programs" for the tens of millions of individuals most at risk for developing diabetes.
As the New York Times reported:
[T]rained counselors would coach consumers on healthier eating habits and increased physical activity as ways to prevent Type 2 diabetes ... Such programs have been found effective in people with a condition known as prediabetes, meaning that they have blood sugar levels that are higher than normal but not high enough to be considered diabetes.
According to the Times, a YMCA pilot program has already proven successful for significantly improving health and reducing medical spending:
Federal officials said that Medicare saved $2,650 for each person enrolled in the prevention program over 15 months, compared with similar beneficiaries not in the program. That was more than enough to cover the costs. In addition, officials said, Medicare beneficiaries in the program lost about 5 percent of their body weight, which was enough to reduce substantially the risk of future diabetes.
Such a proposal formally recognizes the importance of integrative health programs that provide holistic, preventive treatment to individuals, an initiative that is especially important for individuals with mental illness. We may intuitively understand that exercise improves quality of life and decreases symptoms of depression, anxiety and other mental illnesses. In practice, however, social service providers too often treat mental health and physical health as separate domains.
"[Mental heath and physical health are] the same thing," Manocchia said. "There's no difference in those two things really. I don't know why there are separate words for them ... you can't have one without the other."
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