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Small steps can yield big results

March 1, 2009
by Dori Hutchinson, ScD
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You don't need to reinvent the wheel to help people live healthier

The notion that we are a “supersized nation” has been offered as one of the many reasons why Americans are struggling with healthy nutrition and body weight. This idea suggests that bigger is better, and this is equated with satisfaction and satiety. I wonder if this notion, that bigger is better, also has invaded our perception of transforming mental healthcare.

I recently explained to some public health professionals the array of health-promotion services our recovery program at Boston University offers. At the end of my presentation, a psychiatrist remarked that our program was like the Mount Everest of recovery-oriented services that promote holistic health. That is, he was a hiker at the mountain's base looking up, feeling completely overwhelmed by the “supersized” changes that his system would need to effect changes in people's health. His comment struck me as it reflects what I believe happens on individual and system levels when we attempt to make health changes.

Every New Year's Day, many people proclaim new and renewed resolutions to live a healthier life. These proclamations often require major life transformations, and they quickly fall apart due to lack of skills, knowledge, support, time, financial resources, attitude, and motivation. The vision of a healthier life is seductive, even irresistible, but we often supersize our steps to attaining our goal of living well and living longer. I need to lose 25 pounds by March; I will run the Boston Marathon in April; I will quit smoking cold turkey on Tuesday-these are inspiring and hopeful goals, but often unattainable in such large chunks.

The same experience happens at the program and system levels. We rationalize that if we are to provide any type of health services or interventions, we need to have an exercise room, staff to accompany people on walks, and a larger budget. Yet given our current healthcare and economic crises, such goals feel overwhelming, creating anxiety and even hopelessness.

Food education and mindful eating is part of the recovery education program curriculum at the center for psychiatric rehabilitation at boston university

Food Education and Mindful Eating is part of the Recovery Education Program curriculum at the Center for Psychiatric Rehabilitation at Boston University. Photos courtesy of the Center

Thinking big but starting small

The National Vision of Wellness and the 10 by 10 Campaign, to reduce the mortality disparity of persons with mental illness by 10 years in 10 years, are inspiring, hopeful, and critical (For more details, see The campaign's goal is attainable. This campaign and the related research base, supporting the need to change how we help people live longer and healthier lives, have heightened our awareness and understanding of the lack of focus on health in mental health consumers' lives. They have inspired a needed outrage at the fact that people with mental illness are dying from preventable diseases too young while under our care and influenced by our practices.

At the same time, the 10 by 10 Campaign has fueled a perception that to achieve this goal, we must make huge changes right now on every level: individually, programmatically, and systemically. Although huge changes will be required in how we practice and administer our services, small steps can be taken right now. Meaningful-but not supersized-transformation can occur at every level to effect sustainable change that will enhance people's health, improve functioning, and increase opportunities to work, learn, and love.

When I visit outpatient and inpatient mental health programs across the country, I am struck by how unhealthy I feel while in these environments. Policies prohibit going outside unless on a smoking break. Informal structures, such as excessive TV watching and computer use, promote inactivity, which constrains optimal health. These factors influence our sense of well-being.

Staffs' common response to my concerns is to label the individual behavior in response to the environmental expectation. People are judged as accountable for the consequences of our programs. I even have heard staff protest that “making people go outside if they don't want to” violates patients' rights. The very values of choice and self-determination are used as barriers to changing our practices.

Therein lies a major problem in the mental health community. Our expectation is that people cannot attain or sustain health, and that our programs can't afford to make the changes necessary to promote their health. If we were to do so, we worry we would violate patients' rights or bump into arcane financial reimbursement restrictions, policies, and practices that maintain a culture of illness.

We have created an unhealthy culture of pessimism, fear, and low expectations of ourselves and people with mental illness. This is our Mount Everest. I challenge us to scale our mountain with small, varied changes on multiple levels.