Experiences of men with psychosis participating in a community-based football programme

Purpose – Physical activity is associated with both physical and mental health benefits for people with psychosis. However, mental health services have been criticised for failing to adequately promote physical activities. Occupational Therapy, with its focus on meaningful everyday occupations, is well placed to incorporate physical activity interventions. The purpose of this study was to explore the experiences of men with psychosis participating in an Irish community-based football programme. Design/methodology/approach – Six men with psychosis participated in qualitative interviews. The interviews were audio-recorded and transcribed verbatim. Interview data were analysed thematically. Findings – Participants identified many benefits of engaging in the programme. Football became a valued part of weekly routines and fostered re-engagement with previously valued roles. Participants identified improvements in social confidence and motor and process skills, as well as a positive impact on their mental and physical health. Originality/value – This study highlights the value and meaning of participation in football for men with psychosis, as well as demonstrating the longer-term feasibility of football as a therapeutic medium in Occupational Therapy mental health service provision. Findings could help to promote the routine use of sports interventions to mental health services.


Introduction
In addition to a range of physical health benefits, physical activities such as football can lead to improvements in psychotic symptoms, mood, alertness and concentration, sleep, selfesteem and the development of a positive identity (Alexandratos et al., 2012;Hutcheson et al., 2010;Mason and Holt, 2012). However, there is limited evidence on how physical activity is actually experienced by people with psychosis (Alexandratos et al., 2012).

Literature review
Physical activity and mental health services While physical activity can contribute to improved quality of life through social interaction, meaningful use of time and purposeful activity (Alexandratos et al., 2012;Hutcheson et al., 2010), people with psychosis are vulnerable to exclusion from sports because of a number of factors, including weight gain, difficulties with motivation and self-care, lack of routine, social isolation, lack of support, financial difficulties and a perceived lack of opportunities to access community resources (Carter-Morris and Faulkner, 2003;Cole, 2010;Hodgson et al., 2011). The Department of Health's policy framework, Healthy Ireland (Department of Health, 2013), promotes the development of programmes to encourage vulnerable populations, including those with mental health problems, to engage in physical activity. While the mental health policy A Vision for Change (Department of Health and Children, 2006, p. 41) acknowledges that membership of a sports club or football team conveys "the benefits of physical exercise [. . .] sense of belonging [. . .] social contacts and support", it does not actively direct mental health services to offer their clients opportunities to engage in sports. Similarly, mental health service providers have been criticised for not devoting enough attention to the promotion of physical activities (Carpiniello et al., 2013), with both staff and service-users reporting a lack of structured and accessible activity (Hutcheson et al., 2010).
Service-users may experience synergistic benefits from physical activity programmes delivered by mental health services working with community-based sports organisations (Hodgson et al., 2011;Nyboe and Lund, 2013;Spandler et al., 2013), with the integration of physical activity into mental health service provision forming a "critical component" of recovery-focused interventions (Richardson et al., 2005, p. 329). There is a need for healthcare professionals using football as an intervention to explore how physical activity is experienced by people with psychosis (Alexandratos et al., 2012), with qualitative research in particular key to furthering understanding of the effects of exercise from the participants' unique perspectives (Mason and Holt, 2012;Mutrie, 1997). A review by Alexandratos et al. (2012) highlighted a further gap in the literature regarding the feasibility of longer-term physical activity programmes, as most of the included interventions were short term with limited follow-up.
Physical activity as an occupational therapy intervention Occupational Therapy can facilitate community-based participation for people with mental health problems (Pieris and Craik, 2004) and is well placed to incorporate physical activity interventions into meaningful everyday occupations (Alexandratos et al., 2012;Jones, 2008). Fiona Cole (2010) illustrated the value of the Model of Human Occupation (MOHO) in conceptualising the physical activity experiences of people with mental health problems. MOHO (Kielhofner, 2008) examines how volition, habituation, performance capacity and the environment interact to produce occupational performance or dysfunction. However, Cole's study focused on people with anxiety or depression and who had expressed an interest in physical activity. The present study builds on this work by including men with psychotic disorders who were actively engaged in physical activity.

Experiences of men with psychosis
The main aim of this qualitative study was to explore the subjective experiences of the participants of a community-based football intervention, the KSRP. A secondary aim was to report the long-term feasibility of this intervention delivered as part of an Occupational Therapy programme.

Methods
The kickstarting recovery programme The setting for this study was an urban state-funded mental health service in Ireland, consisting of 13 multidisciplinary mental health teams, 3 multidisciplinary rehabilitation and recovery teams and a homeless service. Participants in the Kickstarting Recovery Programme (KSRP) had a diagnosis of psychosis and came from across the service.
The KSRP emanated from a lack of opportunity for service-users to engage in valued sporting activities. Service-users had expressed an interest in playing football but were unable to access existing community resources. KSRP was a joint initiative of the mental health service's Occupational Therapy department, the Football Association of Ireland (FAI) and the local county council to facilitate participation in football for persons with psychosis.
The aim of this qualitative study was to explore the subjective experiences of participants of a community-based football intervention, the KSRP, from an occupational perspective.

Study design
This qualitative study explored the experiences of men with psychosis participating in a community-based football programme, from an occupational perspective. As the aim of the study was to explore experiences using subjective accounts of participation, a qualitative design was chosen (Cole, 2010;Craik and Pieris, 2006).

Ethical considerations
Ethical approval was sought and granted by the Health Service Executive's local mental health research ethics committee. All participants provided written, informed consent. Pseudonyms are used throughout this document to preserve anonymity. Because of the nature and content of the interviews, it was not anticipated that interviews would cause distress. However, each participant's keyworker was informed of their participation and was available in case the need for support arose during or following an interview.

Programme delivery
The KSRP was initially piloted in September 2012 for four weeks, with a weekly one-hour session in a local community centre facilitated by an experienced FAI coach. All serviceusers received clearance from a medical doctor before participation. There have been 12 cycles of training sessions to date (January 2016), with each cycle initially lasting four to six weeks. In 2015, the programme ran for the majority of the year, breaking for eight weeks over the summer and finishing in early December. The number of participants per session ranged from 3 to 18, with a mean of 8.7 participants (SD = 3.1). In all, 74 individuals have taken part (71 male; 3 female), the majority of whom were diagnosed with a psychotic disorder (76 per cent). At least one occupational therapist also participated in each training session and provided grading and adaptation of instructions and exercises when necessary. Activities were, thus, tailored to each individual's level of ability (Cole, 2010;Creek, 2003). Each session began with a warm-up, continued with skill drills and finished with a match, followed by refreshments in a coffee shop.

Participants
Service-users were eligible to participate if they had attended at least one full cycle of training (4-6 sessions) and were considered by a mental health professional to have the capacity to give informed consent and participate in a qualitative interview. In all, 12 potential participants, all with diagnoses of psychotic disorders, were personally invited to participate by the first author at the end of a training session. Six agreed to take part. All participants were single Irish Caucasian males, with a mean age of 32.8 years (range 20-49). All participants were prescribed atypical anti-psychotics in combination with other psychiatric medications (Table I).

Qualitative interviews
Semi-structured qualitative interviews were used to explore the subjective experiences of participation in KSRP from an occupational perspective. Qualitative interviews are particularly suitable for exploring participants' engagement in sports (Carless and Sparkes, 2008) and provide an opportunity for detailed investigation of personal perspectives and in-depth understanding of the personal context within which research phenomena are located Spencer et al., 2003). Each interview began with a set of warm-up questions regarding participants' hobbies and routines ("what do you do to enjoy yourself in your spare time?") and explored their interest in football ("do you support a team?"; "would you watch football on TV"?). The remainder of the interview schedule was structured around MOHO (Kielhofner, 2008) exploring volition, habituation, performance capacity and environment (see Table II for sample questions). Semi-structured interviews were conducted between February and July 2014 by an occupational therapist external to the programme. Interviews were conducted in quiet locations chosen with the participants, lasted between 30 and 50 minutes and were audiorecorded and transcribed verbatim.

Data analysis
Thematic analysis followed two key stages identified by Ritchie et al. (2003): managing the data and making sense of it through descriptive accounts. Data management began by sorting and reducing the data. Initially, a set of 20 codes was devised, based on the research aims, interview schedule and data from the first four interviews. To ensure rigour and trustworthiness and to promote dependability (Pope et al., 2000;Smith and Firth, 2011), each transcript was then coded independently by two researchers. At this stage of the analysis, a number of codes were combined because of considerable overlaps, resulting in a final Experiences of men with psychosis number of 14 codes (Braun and Clarke, 2006). The coded material was then synthesised and summarised into descriptive accounts, identifying key dimensions and mapping the range and diversity of each phenomenon while reducing the volume of verbatim quotes from respondents Ritchie et al., 2003). The next stage was to identify ways in which the codes could be grouped into fewer, broader categories or themes . As we were particularly interested in exploring the participants' experiences of the programme from an occupational perspective, we identified themes in a theoretical, deductive manner (Braun and Clarke, 2006), ensuring they were not unduly influenced by our theoretical interest in the Model of Human Occupation. Four main themes emerged: positive experiences of playing football; football as part of a weekly routine; improvements in skills; and environmental factors.

Trustworthiness
To minimise potential bias at both the data generation and data analysis stages of the study, participants were interviewed by an occupational therapist external to the programme, with data coded independently by two researchers. Codes were initially developed inductively (Cole, 2010). This open coding ensured that all data items received equal attention in a thorough, inclusive and comprehensive coding process (Braun and Clarke, 2006). This also guaranteed the accurate representation of the full range of participants' accounts and ensured that the concepts included in the findings were fully grounded in the data (Lewis et al., 2014).

Findings
The findings will be discussed under each of the four themes: positive experiences; football as part of a weekly routine; improvements in skills; and environmental factors.  The value of KSRP to participants was further highlighted by the fact that all participants wanted to encourage other mental health services and service-users to get involved in similar programmes: I would advise to people that are out there like and they are sitting around doing nothing or lying in their bed to go to their healthcare professional worker and ask for Kickstart Football in their location (Peter).
Alan's description of himself as "somebody who has got chronic schizophrenia" illustrates how his sense of identity was linked to an internalisation of his role as a patient. Alan appeared to experience a significant role shift as a result of participation in KSRP, from somebody with schizophrenia to "a member of a team": These excerpts highlight the value and importance of KSRP to the participants, who identified feelings of achievement, effectiveness, satisfaction and enjoyment as a result of engaging with the programme. This was further solidified when all participants sought to encourage others to share their positive experiences by participating in the training sessions. KSRP facilitated the forging of a new identify for one participant, moving away from a "sick role" towards a more inclusive "member of a team".
Football as part of a weekly routine Participants reported varying levels of activity throughout their week, ranging from "very boring" (Alan) to "busy" (Richie). Routines were either leisure and home-based or focused on health-centre activities, such as getting a depot injection or participating in an activity group: These accounts illustrate the importance and value the participants placed on engaging in football as part of their weekly routinehaving somewhere to go, having something to look forward to and having an alternative to just "sitting around".

Improvements in skills
Participants' awareness of their performance capacity was evident in descriptions of their skills and abilities. Improvements in process and motor skills related to football were noted by participants. Tony described how his "passing has improved", while Alan highlighted improvements in his overall abilities: "I just feel like I can, I can play better than I used to [. . .] I'm more hungry to score goals". Mark noted the return of motor and process skills that he had once possessed: Mark also highlighted that his attention was better than usual while playing football: Other times I could be sitting at home watching the news and me mind would just drift off but when I'm playing football me eh concentration is 100 per cent [. . .] I'm fully focused on the game (Mark).
Participants also noted physical benefits of participation in the programme, including improved fitness levels, weight loss, having more energy, sleeping better and feeling healthier and more active: "I feel great I do since I started playing football, I just feel more fitter and I lose the weight" (Peter). The relevance of interpersonal and communication skills was particularly evident when participants described the teamwork element of playing football, such as giving "tips to your teammates and all that" (Mark). Social benefits of participating in KSRP included making new social connections and providing a topic for conversation, which facilitated improvements in social skills and confidence: Participants identified subjective improvements in various aspects of physical and mental well-being, including improved football and social skills, more focused attention, increased fitness and energy levels and improved weight management and sleeping patterns.

Environmental factors (physical and social)
Participants were positive about the physical environment in which the football sessions took place, reporting that the location and facilities were "lovely": It's a nice area [. . .] it's a lovely spot, outdoor astro and if there is good weather like this or on a summer's day I might play outdoors but if it's bad weather, if it's a bit cloudy or cold we play indoors in the hall (Richie).
Couldn't be better, brilliant. It's in the middle, it's between here and town so it's convenient to get to (Alan).
The involvement of professional FAI coaches provided an important resource that facilitated participation and performance, described by Frank as "good motivation". Participants highlighted the coaches' professionalism and the support they provided: "I think that's good yeah, it brings more in-depth training to the, that I mightn't get elsewhere [. . .] the exercises or the drills are more professional" (Tony). Peter also described the occupational therapists and coaches as "very supportive": They encourage us [. . .] they are very professional as well, so the two of them work hand-in-hand they do (Peter).
The social environment was highlighted frequently by all participants as being an important aspect of their engagement with KSRP. This included a "cup of coffee" after training and people to talk to: We all have good craic [fun] we do and we all have a laugh and a joke after then. We all sit there and have a cup of coffee or tea or soft drinks or ice pops and we all have a good chat after (Richie).

Discussion
The aim of this qualitative study was to explore the subjective experiences of men with psychosis participating in a community-based football programme, from an occupational perspective. Football became an enjoyable and valued part of participants' weekly routines and not only fostered re-engagement with previously valued roles, but also the development of new roles and identities. Participants identified improvements in social confidence and motor and process skills related to playing football, as well as experiencing a positive impact on their mental and physical health.
Football as a valued occupation Participants clearly described how playing football became an important and valued part of their weekly routines, something they looked forward to. The integration of leisure activities into individuals' routines has previously been noted as an important factor facilitating continued participation (Pieris and Craik, 2004). A valuable and meaningful weekly routine is an important part of the recovery process, as well as in shaping who we Experiences of men with psychosis are and how we identify and interact with the world (Forsyth and Kielhofner, 2006). Jones (2008) proposed that with the right encouragement and support from occupational therapists and technical instructors, individuals with psychosis could experience and interpret physical activity in a positive light and anticipate future sessions through the volitional cycle (Jones, 2008;Kielhofner, 2008). This is supported by the present study, as participants described how they looked forward to training each week. Re-engagement with previously valued roles is another key aspect of recovery and was a clear benefit of participation in KSRP. One participant was actually able to forge a new role and identity as a result of his participation, as a "member of a team [. . .] somebody who matters" (Alan). This is consistent with a previous study of a football programme for people with mental health problems, which found that playing football offered participants a reconnection with a pre-illness identity and was associated with enjoyment and a positive sense of self (Mason and Holt, 2012).
All participants reported that participation in KSRP had a positive impact on their mental health, highlighting that football helped them cope with their illness and provided hope that they could recover. Participants also described how participation in the programme provided a distraction from psychotic symptoms, led to improvements in concentration and alertness and improvements in self-esteem. These findings are consistent with previous research (Alexandratos et al., 2012). KSRP offered men with psychosis the opportunity for social interaction in the context of a normalising activity, thereby helping to reduce social isolation for individuals who are particularly vulnerable to becoming socially excluded from the society (Mason and Holt, 2012;Department of Health and Children, 2006;Hodgson et al., 2011). Indeed, participants identified improvements in social confidence as a result of involvement in KSRP and reported that having a common interest improved their ability to interact with others.
A partnership approach to mental health recovery Irish health policy promotes the use of collaborative community partnerships, encouraging mental health services to use a community development model to embrace the synergistic effects that can be achieved through multi-agency working (Department of Health, 2013). The KSRP achieved this synergy through the use of community resources and facilities, coupled with the professional experience and expertise from participating FAI coaches and occupational therapists. Participants themselves wanted to encourage other services and service-users to recognise the value of KSRP and to adopt it in their own services. Building closer links with community resources can facilitate continued participation as well as fostering social inclusion (Hutcheson et al., 2010;Jones, 2008), and participants were positive about both the physical and social environment in which the football sessions took place.

Feasibility of Kickstarting Recovery Programme
The KSRP has been running successfully since 2012 and continues to attract an average of eight participants per session, with a total of 74 individuals having attended overall (up to January 2016).
This study adds to the growing body of evidence supporting the use of football as an intervention in mental health. Occupational therapists are in an ideal position to promote the use of sports and physical activity, as well as to facilitate community-based participation for people with mental health problems (Alexandratos et al., 2012;Jones, 2008;Pieris and Craik, 2004). This study illustrates the longer-term feasibility of incorporating football into an Occupational Therapy programme, as well as its acceptability and value to a vulnerable, hard to reach population. The programme has since been adopted by a further seven mental health services throughout Ireland. The continued success of KSRP, both in terms of sustained interest and participation from service-users, underlines the importance of culturally meaningful, age-and sex-appropriate activity that is of interest to participants (Cole, 2010).

Limitations and strengths
A number of limitations should be noted. Only a sub-sample of participants from the programme were interviewed, and it is possible that the views of non-respondents may differ from those who were selected and chose to take part (Mason and Holt, 2012). The difficulty of recruiting participants with severe and enduring mental health problems has been noted by previous studies (Jones, 2008;Beebe, 2007), with sample sizes ranging from 2 to 12 participants in a review by Alexandratos et al. (2012). While it is not possible to make claims regarding representativeness based on the intensive study of a small number of cases (Denscombe, 2010), nevertheless insights into the experiences of participants in the KSRP might encourage other occupational therapists to consider a similar programme as part of their service delivery. This study provided a unique opportunity to explore the value and feasibility of a community-based football programme, generating an interpretation of existing research from the views and personal experiences of people with psychosis themselves (Alexandratos et al., 2012;Pieris and Craik, 2004).

Future studies
Future studies could explore participation in other forms of physical activity, including those that may be of greater interest to women. We hope that our findings will inspire other mental health services to prioritise physical activity interventions equally with activities of daily living and productivity (Jones, 2008).

Conclusion
This study has highlighted the value and meaning of participation in football for men with psychosis, as well as demonstrating the longer-term feasibility of football as a therapeutic medium in Occupational Therapy mental health service provision. These findings may help to promote the routine use of football and sports interventions to other mental health services.