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Small steps can yield big results

March 01, 2009

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.

Promoting health in our programs is more than just providing information about healthy practices. It involves changing the program's behavior as well as the physical and social environments. It's about developing and advocating for policies, including financial incentives, that support health for everyone in the environment. It is about empowering individuals and environments to make informed decisions about health and practice. And it is not about reinventing the wheel. Significant health-promotion evidence, practices, and curricula are applicable, with commonsense modifications, to people with mental illness (table).

Walk your talk

Consider starting with the language you use in your programs. Talk about wellness; ask people how they define it; and encourage people to share their wellness vision. Encourage both employees and consumers to share their health struggles together, strategize together, and support one another, as we hold the power to influence and inspire each other.

Many of us were trained to refrain from personal disclosure about such topics in clinical relationships. Program policies may prohibit such discourse. Yet if we are going to develop healthy environments, we must challenge these assumptions. Doing nothing more than engaging in this dialogue could have a positive influence. One woman in our program remarked on this very small but potent strategy: “They talk about wellness with us here, they are always talking about our health, our strengths, and our well-being, and these very words make me feel better!”

Infusing treatment and rehabilitation groups, as well as staff meetings, with wellness language will influence people's behavior and the environment. The message conveyed when we take this very small, and free, step is, “You matter, and your health matters to us.”

Expanding wellness opportunities

It is well known that health behavior is mediated by cognition-that is, what people know and think affect how they act. Providing opportunities for people to increase their health knowledge, health skills, and health attitudes is essential.

Most mental healthcare environments have the ideal infrastructure already in place. Groups are a part of daily life in a mental health program or hospital. Group homes, clubhouses, and consumer-operated services have routines and activities that offer opportunities for health promotion. The table lists some small steps that you might consider in your groups.

In one of the center's classrooms the instructor leads a yoga class, attentive to supporting, adapting, and responding to each student's abilities and needs
In one of the Center's classrooms the instructor leads a yoga class, attentive to supporting, adapting, and responding to each student's abilities and needs.

Whose responsibility is it anyway?

It's not our responsibility to change a person's behavior or lifestyle. Rather, it's our responsibility to change and integrate our systems, programs, and practices to support the possibility, hope, and reality of healthy lives for people with mental illness.

Health, in all its complexities, is a necessary foundation for recovery and a life well lived. No magic pill or long-awaited evidence-based practice will make people and our mental health environments healthier. If we wait with baited breath for such a moment, more people will die prematurely and more people will be burdened by physical disease that will decrease their quality of life. We can take so many small steps right now to have a positive and long-lasting influence on people's health. Many even have no costs.

I am inspired every day by the people, programs, and practices I witness and learn about that promote health. I am optimistic that we will scale our Mount Everest and eradicate the death disparity for persons with mental illness. Strong and committed leadership from all stakeholders is needed to move in the direction of having health, instead of illness, as our framework. Most importantly, this requires remembering that we are talking about a matter of life and death for people, ordinary people, living with mental illness with hopes and dreams of a life well lived.

Dori Hutchinson, ScD, is Director of Services of the Center for Psychiatric Rehabilitation at Boston University

For more information, e-mail


  1. Fitzgerald FT. The tyranny of health. N Engl J Med 1994; 331 (3): 196-8.


Table. Small steps to promote health

  • Offer groups on topics such as:

    • Wellness Recovery Action Planning (WRAP)

    • Illness Management and Recovery (IMR), an evidence-based practice that teaches information, knowledge, and skills to live well and recover despite having a mental illness

    • Tobacco education and treatment

    • Stress hardiness to increase resilience

    • Mindfulness techniques

    • Physical activity, focusing on functional health (walking, yoga, tai chi)

    • Health and food education

    • Sexuality and intimacy education

    • Spirituality

      Curricula, guidelines, and resources for these topics can be found at, or contact me at

  • If reimbursement/financial challenges prohibit developing new groups, infuse the traditional groups with information about health and recovery instead of just a singular focus on the illness. Emphasize information and skills.

  • Include small, attainable health and wellness goals in treatment plans. Help people see the connection between their health and their goals of employment, intimacy, and a full life. Refuse to classify a person's lack of goal attainment as lack of motivation. Resist the urge to control people's health, which might lead to “an increasing peril of a tyranny of health.”1

  • Examine your programs for ways to inspire people to feel hopeful about their health. Create a wellness task force including all stakeholders. Meet regularly. Brainstorm and be creative. Assume an optimistic attitude that barriers can be overcome.

  • Try turning off the TV and offering a movement-oriented activity.

  • Place signs next to elevators inviting people to consider taking the stairs as a healthy alternative. Market and advertise the possibility of health.

  • Create a healthy physical environment-one that is clean, free of unpleasant odors, and provides access to natural light, greenery, water, and fresh air.

  • Offer healthy food choices at meals, meetings, and ceremonies.

  • Allow people outside whether they smoke or not.

  • Respect people's choices about their health whether you agree with them or not. One size does not fit all when health is concerned. Significant cultural differences must be respected.

  • Practice what you preach. Role-model successes and challenges. Staff must believe in the possibility of wellness.

  • Coach people to believe they have the self-agency to make changes, and support their efforts.

  • Tell success stories about people who have improved their health.

  • Hire peers and train them to teach, mentor, coach, and connect about health.

  • Accompany people to health appointments and emergency rooms; offer a second set of ears and advocacy for good healthcare.

  • Train providers and staff in our own communities, as well as the larger health communities, about the health disparities that people with serious mental illness experience. Empower, inspire, and incentivize healthy changes in attitudes, practices, and policies.

  • Connect people to community resources. Seek out and collaborate with community resources to provide opportunities and services. Advocate for community resources such as reduced-cost YMCA memberships.

  • Use Web sites such as,, and for easy, user-friendly suggestions, messages, and tips on health.

Behavioral Healthcare 2009 March;29(3):26-29
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