Journal of Mental Health Counseling Volume 25/Number I/January 2003/Pages 45-56 Exercise as a Counseling Intervention Verna O. Okonski The focus of wellness counseling is to guide individuals to live a healthy life in which body, mind, and spirit are integrated in order to experience fulfillment and happiness. Exercise undoubtedly has physical and psychological benefits in the human body and spirit. However, adherence to exercise has proven to be the greatest obstacle in getting individuals to experience the benefits of exercise. In addition, there is litle research that gives counselors guidelines on how to use exercise as a ther- apeutic tool. The purpose of this article isto provide counselors steps to follow when using exercise as a counseling intervention and to provide techniques that will encourage exercise adherence. The focus of wellness counseling is to guide individuals to a lifestyle of opti- mal health and well-being in which body, mind, and spirit are integrated for a balanced and fulfilling life (Myers, Sweeney, & Witmer, 2000). Exercise has Jong been considered an important aspect of wellness. For example, exercise is identified in Myers, Sweeney and Witmer’s Wheel of Wellness Model. In addition, Myers et al.'s model identifies five life tasks that every individual needs to acquire in order to live a fulfilling and healthy life. Exercise plays an important role in helping people obtain wellness and a healthy lifestyle because of its physical and psychological benefits. Many mental health coun- selors may be reluctant to address the issue of exercise or add it to a client’s treatment plan because exercise is not a component of their training. Mental health counselors, however, do not need to be exercise physiologists in order to effectively incorporate exercise as a counseling intervention. Nonetheless, it is important that counselors know how to integrate exercise as an inter- vention into the counseling process. The objective of this article is to focus on exercise as an important charac- teristic of a lifestyle of optimal health and well-being. Mental health coun- Verna O. Okonski is a research assistant and doctoral student, Child, Family, and Community Sciences, University of Central Florida, Orlando. E-mail: vernaokonski@msn.com 4546 JOURNAL OF MENTAL HEALTH COUNSELING selors who focus on wellness need to know how to incorporate exercise into the counseling process, Unfortunately, there is little research on specific coun- seling techniques necessary for compliance to an exercise program, and there are no clear steps for counselors to follow when using exercise as a counsel- ing tool. Another important issue to address is clients’ motivation to comply with an exercise program. This article will describe how mental heaith coun- selors can incorporate exercise as a counseling intervention. These sugges tions will focus on both client motivation to exercise and client adherence to an exercise regimen. EXERCISE IN COUNSELING Counselors must have a general understanding regarding exercise when incorporating exercise into the counseling session. It is important for the mental health counselor to have a clear definition of exercise, which is defined in this article as any type of physical activity, aerobic or anaerobic, with the means of integrating the mind, body, and spirit. Furthermore mental health counselors should have broad knowledge regarding key areas utilized when creating or implementing an exercise program such as physical inten- sity, exercise program tailoring, frequency of exercise, convenience of the exercise regimen and exercise facility, safety in exercising, locus of control, and perceived self-efficacy. The aforementioned key areas are discussed in detail throughout the article. In addition, counselors need to be aware of the techniques and interven- tions necessary in implementing exercise into the counseling process. An important aspect of the general information (discussed above), techniques, and interventions is its focus on client compliance to an exercise program. Although there is research suggesting that behavior modification has a greater impact on increasing physical activity than other approaches such as cognitive-behavioral modification, health education, and physical education curriculum (Dishman & Buckworth, 1997), there is little research regarding which of the many different behavioral modification strategies and tech- niques best motivate adults lo exercise. Two techniques in behavior modifica- tion that have brought about the most success in adherence have been behay- jor contracting and stimulus control (Owen & Sallis, 1999). A behavior contract is an appropriate technique to motivate adults to exer- cise because it creates intrinsic motivation, is an individualized technique that increases locus of control (Homme, & Hazler, 1999; Homme, Csanyi, Gonzales, & Rechs, 1970; Kelley & Stokes, 1982: Langstaff & Volkmor, 1975), creates consistency of goals (Gambrill, 1987; Tharp & Wetzel, 1969), encour- ages active participation and sclf-determination (White-Blackburn, Semb, & Semb, 1977), and is widely used to teach independence and self-control (Homme, Csanyi, Gonzales, & Rechs, 1970; Kabler, 1976). Behavior contract-Okonski / EXERCISE INTERVENTION 47 ing has also been used successfully by clinicians to treat problems such as smoking (Prochaska, Velicer, Guadagnoli, Rossi, Diclement, 1991}, obesity (Mann, 1972), and alcohol dependence (Miller, Hersen & Eisler, 1974), In addition, Wysocki, Hall, Iwata, and Riordan, in 1979, increased the amount and regularity of physical exercise of seven adults through “deposit contract- ing,” which is a form of behavior contracting. Although this study demon- strated that behavioral contracting increases physical activity, this particular study only had seven subjects and the small sample size does not give gener- alizable credibility to its findings. Stimulus control is a behavioral technique in which prompts are supple- mentary stimuli used to increase the likelihood that an individual will emit a specific response such as exercise in the presence of the stimuli that will even- tually control behavior (Billingsley & Romer, 1983; Snell, 1983). When using the technique of stimulus control, the first step is for the client to self-moni- tor his or her exercise behavior. After completion of the first step, the client and counselor should work on developing an environment conducive to pro- moting exercise (Dishman, 1988). The time, place, and individuals that com- pose the environment for exercise will then represent the cues for those who adhere to the exercise program. In order for adherence to an exercise pro- gram to occur, an important factor to take into consideration is the decreas- ing of cues for competing behaviors (Martin & Dubbert, 1987). The mental health counselor can promote this process by helping the client identify spe- cific times and locations that promote adherence, so that there are no com- peting cues, and the individual can successfully adhere to his or her exercise program. One example is placing exercise photos on the refrigerator door as a constant reminder (Dishman). Tt could be concluded, after reviewing the research on behavioral modifi- cation and the techniques used in most exercise programs, that the combina- tion of two behavioral techniques, behavior modification and stimulus con- trol, will have a greater effect on motivating adults to exercise than using behavioral modification or stimulus control alone. By researching each tech- nique on its own, one could determine what types of combinations within behavior modification techniques will work most effectively in promoting exercise adherence. EXERCISE IMPLEMENTATION INFORMATION It is important to remember that counselors are not to take on the role of personal trainer or exercise psychologist: rather, mental health counselors are focused on the mental health outcomes or the wellness aspect of exercise. They need to help clients become aware of the psychological and physiologi- cal benefits of exercise and of ways to adhere to an exercise program of their choice.48 JOURNAL OF MENTAL HEALTH COUNSELING Generally, the individuals that are most likely to adhere to an exercise pro- gram are men, people with a past history of physical activity, those with higher levels of education and income, and younger individuals (Dishman & Buckworth, 1997). Smokers, blue collar workers, and individuals that have a low self-efficacy regarding success in an exercise program are most likely to drop out. Other factors that have a negative impact on exercise adherence include a lack of access to an exercise facility, a perceived lack of time, lack of client's family support regarding participation in the exercise program, lack of encouragement [rom counselor or group members, and injury. Another factor to take into consideration is that research has indicated that exercising alone will result in a greater dropout rate than exercising as a group. To increase adherence to physical activity, a combination of techniques or intervention strategies that can benefit all clients is necessary. One should not, however, overlook independent client tailoring. While behavior modi cation has, to date, proven to be the most successful technique in exercise adherence, it is suggested that mental health counselors combine four behav- ior modification techniques—contracting. self-monitoring, goal setting, and stimulus control—when incorporating exercise into the counseling session. While all four behavioral techniques are important contributors to a success- ful exercise program, contracting and stimulus control are thought to be the promoters of exercise adherence behavior, while goal setting and self-moni- loring help maintain exercise adherence behavior. To help mental health counselors incorporate exercise into the counseling process, the following suggestions are provided. IMPLEMENTING EXERCISE IN MENTAL HEALTH COUNSELING Determining Appropriateness of Exercise Mental health counselors need to know when it is appropriate to incorpo- rate exercise as an intervention for a client. It is critical to the success of the exercise program that the mental health counselor continue to develop a good client-counselor rapport and working alliance through a caring and nur- (uring environment as counselors would in any other counseling session, Due to the fact that not all interventions are appropriate for all clients, applying exercise as a counseling intervention should be implemented in the same manoper as other interventions by evaluating the appropriateness or the ben- efit of using exercise as a counseling intervention with each individual client. For example, the counselor should decide if the client could benefit from exercise. In addition, the counselor should evaluate the client’s readiness for utilizing and adhering to exercise. Counselors need to become educated with respect to the issues and disorders for which exercise is indicated to bring about the most benefit in its utilization as a counseling intervention. In considering the appropriateness of physical activity as a counselingOkonski { EXERCISE INTERVENTION so intervention, it may be useful for the mental health counselor to consider research that shows exercise to be beneficial in the mental health counseling field. Research suggests that exercise can decrease symptoms of depression (Martinsen & Morgan, 1997), assist in diminishing of anxiety (Raglin, 1997), increase self-mastery feelings (USDHHS, 1996), be a buffer against stress (Roth & Holmes, 1985), and increase self-esteem (Sonstroem, 1997). However, little has been concluded through research as to the specific tech- niques that wil! bring the most success in exercise adherence and motivation. Both behavior modification and cognitive behavioral methods have demon- strated success in reducing the dropout rate of exercisers. Most exercise pro- grams ordinarily use a multimodal approach that includes utilizing reinforce- ment for healthy behaviors, contracting, self-monitoring, instruction, model- ing, goal setting, increasing self-efficacy, and assisting in relapse prevention. Psychological interventions have indicated improvement in adherence to physical activity programs by roughly 15% to 20% (Dishman & Buckworth, 1997). Once the mental health counselor determines that exercise is indeed appropriate for a specific client, the counselor needs to bear in mind several precautionary steps. Before an individual begins an exercise program, it is necessary to consider safety precautions in relation to the client's capacities, limitations, and health. For example, an individual who has a heart condition should obviously not engage in strenuous activities. In addition, there are cer- tain medications that may have an adverse effect when the individual increases his or her physical activity. Every counselor needs to recommend that his or her clients see a medical doctor prior to engaging in any new exer- cise program. Consent for the mental health counselor to consult with the clients medical doctors can be extremely beneficial in preventing physical injuries. Utilizing exercise as a counseling intervention will not be appropriate for all clients. Through screening, mental health counselors identify their client's presenting problem. Once the client’s presenting problem is identified, or the issue that the client would like to work on is clearly delineated, the coun- selor’s role is to determine if exercise will be beneficial to the client. Exercise may not be appropriate to utilize as a counseling intervention with certain diagnoses such as eating disorders. If the counselor identifies disorders or problems that their clients are facing which are exercise-induced, then it is the role of the counselor to reduce the amount of exercise to an appropriate level with a fitness goa! rather than a psychotogical issue such as a means of control. Roles and Responsibilities One of the first roles of a mental health counselor is to develop goals that50 JOURNAL OF MENTAL HEALTH COUNSELING are individualized in order to meet each client's needs. Common goals in an exercise program include improving stress management, improving self- esteem, or reduction in weight. To determine the client’s goals, his or her needs should be clearly identified. Then, the goals should be flexible, and the goals need to be individually tailored. Goals should also be realistic with respect to the time necessary to achieve the goal and the client’s expectations. For example, it is more effective to set smaller, more achievable goals so the client can experience success (Annesi, 1996), Contracting is a technique that the mental health counselor can utilize in conjunction with the technique of goal setting. The counselor needs to develop a contract that will clearly describe the exercise program, the clients” goals, the benefits of exercising, and what is expected from the client (e.g. how many times a week he or she will exercise). It is also important for the coun- sclor to be aware, before developing the contract, of the client’s readiness level. The readiness for change theory has received wide acceptance and use by health care practitioners. This theory addresses the individuals’ ability to make changes based upon their emotional and intellectual readiness to change (Prochaska et al., 1991). Clients can be evaluated as to the stage of readiness they are in, before being given the challenge to change their behav- jor, Once the client signs the contract he or she is assuming responsibility for the exercise program and the goals become intrinsically embedded. Another important role of the mental health counselor is to make sure that the exercise program is enjoyable for the client and that the client learns to value the benefits of exercise. Mental health counselors should be aware that it may take some time to find the type of exercise that is enjoyable for each client. There is an array of exercises that an individual has to choose from, and this search should be guided by the mental health counselor, However, there may be cases in which clients truly do not find the act of exercising enjoyable even after an extensive search of different types of exercises; in this case the counselor should have the client focus on the enjoyment the client might feel in living a healthy lifestyle and becoming physically fit. Some clients’ enjoyment may be developed by the body changes that can be produced through exercise such as weight loss or increase of muscle tone and definition. By maintaining a level of enjoyment, the individual will feel motivated to continue with the exercise program. Frequently, asking the client his or her level of enjoyment will increase maintenance. In addition, those clients who believe in the value of exercise for their specific benefit have a greater possibility of incorporating and maintaining exercise as part of their lifestyle (Dishman, Sallis, & Orenstein, 1985). Mental health counselors should encourage their clients to continue exer- cising and should point out the progress that their clients have made. ClientsOkonski / EXERCISE INTERVENTION Sr will also likely receive emotional support from other individuals that exercise with them. This group support should be encouraged by the counselor (Martin & Dubbert, 1987). In addition, it is the counselor’s role to keep the client's attitude positive and enthusiasm high. An example would be the counselor stopping an individual from doing too much too soon and conse- quently losing interest (Ribisl, 1984). In regard to support, it is important for the client to feel that his or her family supports the changes in physical activ- ity. Counselors should also be aware and prepared to deal with noncompli- ance in regards to exercise. It is expected that if clients are not motivated to exercise, the possibilities of dropout from the exercise program are high. To facilitate treatment adherence and relapse prevention, the client must internalize the concept that he or she can succeed in this program (Sonstroem, 1997). One way that the counselor can help the client develop feelings of self-efficacy is to carefully arrange exercise assignments that are easily attainable for the client. Research has indicated that to attain exercise adherence, the exercise program must be composed of one small goal that can be reached in a short period of time and a long-term goal (Dishman & Buckworth, 1997). The purpose of the short-term goal is for the client to expe- Tience a feeling of self-efficacy as he or she achieves this goal. Once the client achieves a goal, or sees improvement, the probability that the client will con- tinue with the exercise program and work on achieving the long-term goal increases (Dishman & Buckworth). Another responsibility that the mental health counselor has is to utilize techniques that will enhance adherence behavior. To this end, stimulus con- trol and self-monitoring are two techniques to utilize when guiding clients through a successful exercise program. Continuing patterns of behavior are sustained because they are cued and reinforced as aspects of the environ- ment. For the client, the individuals that they exercise with, the facility they exercise at, and their exercise gear will all become stimulus cues to exercise. ‘The basic strategy necessary in modifying behavior is for the mental health counselor to address changes in the environment that will both support the desired behavior of exercise adherence and weaken the competing behavior ot dropout. The counselor must guide the client to build on and increase the cues that will become exercise adherence-behavior. ‘The initial step in identifying the stimulus control or the cues that will pro- duce adherence behavior is for the clients to self-monitor their behavior when they adhere and when they do not adhere to exercise. After clients observe and record their exercise behavior, the antecedent variables, and any cuing that they may have acknowledged, they can then work with the mental health counselor to arrange an environment conducive to promoting exercise (Dishman, 1988).52 JOURNAL OF MENTAL HEALTH COUNSELING Education of the Effect that Exercise has on the Body and the Aging Process Educating the client on the physiological and psychological effects that exercise has on the individual is an important element of adherence. For example, clients may adhere to the exercise program when they learn that the signs of physical degeneration such as slumped shoulders, sagging skin, loss of vitality, stiff joints, weakness, and fatigue, although inevitable, are slowed by exercise (Lewis, Sperry, & Carlson, 1993). In addition, it would be appropri- ate for the counselor to educate clients on how their bodies are adapting to an overload stimulus in a manner that is specific to the type of training that they are going through as well as explaining the specific muscles that they are using (Fox, 1980). It has already been established that adhering to an exercise program is associated with psychological and physical well-being (Hermon & Hazler, 1999). Due to the health benefits of physical activity, exercise has been pro- moted for many years by an array of professionals including medical doctors and physical therapists (Taylor, Sallis & Needle, 1985). There is an abundance of research suggesting that exercise benefits physical health in areas such as. weight control (Woods & Davis, 1994), cardiovascular health (Dawber, 1980; Gillum, Mussolino, & Madams, 1998), protection against cancer (White, Jacobs, & Daling, 1996), prevention of bone density loss (Nelson, Nevitt, Scott, Stone, & Cummings 1994), and the control of diabetes (Shultz, Sprague, Laurel, & Lambeth, 2001). Given the physical and previously mentioned psy- chological benefits of exercise, one could question: Why do mental health counselors in general not utilize exercise as a counseling intervention when the benefits are so great? Intensity and Frequency of Physical Activity Necessary for Exercise Adherence A general rule of thumb is for the client to exercise al a level that is approx- imately 70 % higher than the client’s resting heart rate. It is important for the counselor to be aware, however, that at the initial stages of an exercise pro- gram, the history of exercise will be different for every client. For sedentary clients, a small increase in physical activity is enough to create an overload. As the client's fitness level improves, greater amounts of work are necessary tocreate an overload and produce change (Ribisl, 1984). Ribisl stated that the principle of progression describes a successful exercise program as applying exercise in a gradual, progressive manner in accordance with the level of fit- ness of each client. The rate of progression should be relatively slow. The pro- gram should last for several weeks because change in physical activity pro- duces muscle soreness, and the body needs time to recuperate, The tailoring of the exercise program is one of the fundamental keys in exercise adherence. Mental health counselors need to help clients decideOkonski / EXERCISE INTERVENTION 53 what type of exercise is right for them. The counselor should also learn rele- vant idiosyncratic information through screening for any physical illnesses that the client might have. If the client is physically healthy, the counselor has a greater number of exercise activities to offer to the client than if the client has some type of physical illness. In some cases, depending on the client's ill- ness and severity, it may not be appropriate for the client to be in an exercise program. In addition, because the threshold for pain, coordination, and phys- ical ability wilt be different from client to client, individuality of training is important for counseling adherence. Tailoring the exercise to the client’s per- sonal goals, history, and lifestyle have been found to increase maintenance of physical activity programs. Research has shown that clients who believed that their program is specifically designed for them continue longer than those who don’t have that same impression (Ganley & Sherman, 2000). ‘There is conflicting research regarding how many times a week an individ- ual should exercise. Some researchers report that an ideal frequency of aero- bic exercise for improving cardiovascular fitness is three times a week. This method of frequency would allow exercisers time to recover. On the other hand, researchers believe that exercising briskly every other day and resting on the alternative days is best. No matter what the latest research on fre- quency of exercise is at the time of developing the exercise contract, it is imperative to consider the client's availability and his or her schedule in order to keep the goals realistic for the individual (Lewis, et al., 1993). Convenience and Safety Convenience and safety should always be discussed throughout the coun- seling sessions. Mental health counselors should make sure that the client per- ceives the exercise program as both convenient and safe. If the client thinks of the exercises program as inconvenient or unsafe, the risk of drop out is high. The mental heaith counselor could decrease the likelihood of drop out from the exercise program by providing time, maybe in the last 10 processing minutes of the session, to give the client a chance to share any problems that may have been encountered with the exercise program. For instance, the client’s schedule might have changed or the time of exercise might not be convenient any longer. In addition, the exercise regimen and the facility at which the client will exercise must be convenient for the client (Martin & Dubbert, 1987). If the client has to travel for an extensive time or views the travel to the exercise facility in a negative manner, then the individual will be less likely to continue with the exercise program (Dishman & Buckworth, 1997). Mental health counselors should guide their clients in finding a loca- tion for exercise and a time that is viewed as convenient to the client. Finally, the safety of the exercise program is one of the most important keys for the success of the program. The mental health counselor is a role model and, in54 JOURNAL OF MENTAL HEALTH COUNSELING being so, should project the value for exercise and the responsibility that comes with it. Although the counselor will not be with their clients as they exercise, safety needs to be stressed. The counselor needs to instruct the client or discuss with the client precautions to take when exercising, such as when Tunning alone at nighttime. Locus of Control Creating an internal locus of control contributes to the goal of the client changing his or her lifestyle into one that values health and wellness of the body and the spirit, as is consistent with wellness models. In order for clients to maintain exercise in their lives, their goals must be intrinsically motivated. Research shows that individuals who believe that they are able to produce change have the highest performance rate (Carter, Lee, & Greenockle, 1987). Individuals who internalize their own reinforcements or are capable of moti- vating themselves experience a high internal locus of control (Dishman, 1988). It is the counselor's role to educate clients on what research has indi- cated with respect to the benefits of exercise goals being intrinsically moti- vated. In addition, the mental health counselor should guide clients on how to internalize their individual goals in order for intrinsic motivation to develop. High internal locus of control has been associated with an increased likeli- hood of healthier behavior. In addition, exercise has been associated with the strength of internal beliefs that leads to high levels of motivation (Steptoe & Wardle, 2001). Motivation is a psychological factor that can explain differ- ences between clients who adhere to an exercise program and those who do not. [f a client is less motivated, the exertion of a physical activity might feel heavier and more stressful than when the client feels highly motivated to per- form physically (Hassmen & Koivula, 1996). Although participation in aero- bic exercise may not produce lifelong changes in psychological functioning, specific changes can occur. These changes may include self-efficacy regarding aerobic exercise and greater internal locus of control of health benefits (Labbe & Welsh, 1993). The goal of the mental health counselor is to help their clients internalize behaviors and thoughts that lead to health benefits, but in the end clients are ultimately responsible for choosing to change their lifestyles. CONCLUSION This article describes and reviews material using exercise as an intervention in mental health counseling. Clear suggestions that a mental health counselor can use when incorporating exercise as a counseling intervention are delin- eated. As Maslow so succinctly stated, “To oversimplify the matter somewhat, itis as if Freud supplied to us the sick half of psychology and we must now fillOkonski / EXERCISE INTERVENTION 5S it out with the healthy part.” As mental health counselors and educators, it is our responsibility and duty to improve or find new ways to guide our clients toa healthy lifestyle. It is my hope that this article brings about more research on the benefits of exercise, the utilization of physical activity in counseling, and a better understanding of wellness issues in mental health counseling. REFERENCES Annesi, J.J. (1996). Enhancing exercise motivarion. Los Angeles: Leisure. Billingsley, FF, & Romer, L.T. (1983). Response prompting and the transfer of stimulus control: Methods, research and a conceptual framework. 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