For this post I interviewed 3 occupational therapists (OT) who have used cycling as therapy with their patients in low, medium and high secure mental health settings. It is the third post in a series about why OTs might like to consider cycling, especially in this time of COVID. Part one of this series gave the views of people with mental health challenges in their own words; part two focussed on things to consider if you as an OT are thinking of incorporating cycling into your practice, regardless of setting. You can find out “how to start cycling” more generally in an earlier post.
- Jacqueline Sharp of the low secure forensic Bretton Centre at Wakefield’s Fieldhead Hospital, part of South West Yorkshire Partnership NHS Foundation Trust
- Roger (not his real name) working on mainly inpatient acute wards in a city health & social care trust (CHSCT). Due to the demands of COVID upon the Trust and the desire to get the blog published Roger suggested including his input anonymously.
- Sarah Innes of the State Hospital’s Skye Centre in South Lanarkshire, the only high secure facility for people with mental illness or learning difficulties.
I’d like to give my thanks to them for sharing their experiences, especially during this very busy time.
Do you need to be a cyclist to set up a cycling intervention?
None of the three OTs were cyclists when their cycling programmes started although one was returning to cycling after 10 years – so she was able to share her anxieties with patients. All had no hesitation in recommending cycling to OTs in settings similar to theirs.
What does cycling as an occupation offer patients and service users?
The OTs interviewed gave a variety of answers.
The opportunity to go off the ward to a new environment, whether outside the organisation’s grounds or not, is seen as a major benefit. It provides a bridge between life on an inpatient ward and life outside, really important whether someone is staying 30 days on a ward or 7 years. Sarah said cycling provides enthusiasm and engagement from both staff and patients, and she can see “light in their faces”. Roger also believes the rides are “a source of solace”.
Cycling away from the ward was also a motivation in itself. As Sarah said:
“Cycling is very good for motivating people. Often they don’t want to leave the ward but cycling provides more autonomy, freedom and responsibility.”
Jacqueline mentioned that one service user would get up for cycling but not for other activities. He also enjoyed the “freedom of the wheels”.
During the pandemic, Sarah said that cycling is also seen as exciting.
For some, cycling provides a link with their life before hospitalisation, creating a continuity in role and identity. For others, it provides a meaningful occupation.
Some people had had difficult childhoods so missed out on the chance to learn to ride a cycle so the programmes are seen as an opportunity to develop new skills and confidence. Others had an opportunity to improve their occupational performance.
Some patients/ service users are overweight, whether due to medication, a lack of activity or eating too much of the wrong foods. (With alcohol and drugs not allowed on wards, people have limited choices and eating sweets is often one of them). Cycling as a physical activity helps to counter this, not least as it is an inclusive activity which enables people who are overweight to exercise.
Roger’s patients were on the ward for perhaps just 30 days so could not attend many cycle rides. However he tried, so far without success, to create continuity for them when they left the ward by encouraging attendance at weekly community cycling sessions using the same cycles in the same park with the same person who supported their cycle rides. Roger thought anxiety about joining a new group – or a lack of confidence to do so – underpinned this lack of success. To maintain occupational engagement though, some service users who have successfully transitioned back into the community, have been allowed to re-join the ward cycle group, albeit limited to only 6 weeks, to ensure there is space for people on the ward to cycle too.
What did the cycle programmes comprise of?
Group, 1:1 rides and games
Group rides and/ or 1-1 rides were available, depending on the patient/ service user and staffing. The environment was graded, with the Bretton Centre and Skye Centre operating in a sports hall (until COVID), potentially progressing to trust grounds, and for the Bretton Centre if people were confident, on to quiet roads, cycle tracks, the canalside and hilly terrain. At the Bretton Centre they also cycled around an athletics track. This gave service users the opportunity to lead, depending on their confidence levels.
The CHSCT programme started and ended with a hot drink in a private room near the cycling start point in a park. People sometimes cycled outside the park, depending on the circumstances.
Games provided an opportunity to learn cycle skills such as road signalling, cycling steadily enough to be able to pass a baton from one person to the next and slow cycling. For the Skye Centre, post COVID it is expected that cycling will continue outdoors if clinically appropriate.
Two programmes offered service users/ patients Bikeability training, but this was not widely taken up. One man at the Bretton Centre who experienced low mood, for example, achieved a Bikeability Level 2 award, which gave him the skills to ride safely on roads.
One programme offered cycle maintenance but no-one was interested. In the past I was involved with a community based team supporting people with mental health challenges where cycle maintenance was offered. The trainer was careful to note which tools had been put out for participants and counted them back before the end of each session.
Patients at the Skye Centre who had acquired Bikeability and sports leadership qualifications were able to access opportunities where appropriate and volunteer, helping design sessions and offering peer support, in turn building their own self-confidence.
One programme included discussions about the right clothes to wear and to carry a water bottle. A cycle check pre-ride was also included.
During the interviews I raised other elements which might fit into a cycling programme such as healthy eating and map reading and these were taken away for consideration.
Which patients and service users cycle?
All the OTs considered carefully whether cycling was an appropriate activity for each person, based on their personal circumstances and occupational needs.
For example, at the Skye Centre the majority of patients are diagnosed with schizophrenia therefore experience barriers to participation associated with negative and positive symptoms of illness. Cycling may not be an option when they first arrive as they are often so unwell but others may already manage well on medication so be able to engage. Another significant consideration which requires to be carefully managed is the risk of violence and aggression, which is often directly linked to symptoms of mental ill health. Occupational therapists work in partnership with clinical teams to carefully risk assess patient’s suitability to participate.
As ever, if patients/ service users want to engage and staff think it fits their personal circumstances, the OTs try to find ways of making it happen.
Managing sensory elements can be important for some. An example discussed from the Skye Centre was where a patient required support to regulate their arousal level towards the end of the group. This patient had a tendency to become overactive later in the day following cycling. The staff manage this by providing a debrief for all participants at the end of the ride to increase the level of calm when returning to the ward.
Patients who had active symptoms of psychosis often found it more difficult to manage cycling due to challenges with processing skills. To support patients to engage the staff at Skye Centre adapt cycle sessions in the following ways:
- by creating a cycle group which carefully considered group dynamics and facilitating a trusting peer group setting;
- by cycling for short periods initially, with appropriate rest breaks and check-in chats;
- if cycling in the grounds is proposed, choosing a quiet time which may offer less distraction from others in the grounds;
- if doing games such as pass the baton, taking time at the start to talk through and think about the plan, and
- offering 1:1 tuition time, where appropriate, to support patients to develop confidence and concentration levels.
People with eating disorders
Physical activity needs to be introduced to people with eating disorders carefully to ensure it is not used by an individual to the detriment of their health. At the Skye Centre, the team work closely with patients and their clinical team to support them to carefully manage their participation in cycling. On rare occasions, some patients may have a break from cycling if they are not managing well but then return when they feel more able to manage. Patients who experience an eating disorder can find cycling beneficial to their mental health, as can any other patient, although this may need to be more closely monitored by staff and the patient themselves, through regular discussions with Occupational Therapy, nursing and psychology staff.
People with a diagnosis of learning disabiity
Sometimes people with a learning disability diagnosis may need extra time to learn to cycle due to barriers in motor and processing skills. Thorough assessment of needs and working alongside the person to understand the barriers to achieving their cycling goal was important at the Skye centre. Adapting the environment was particularly helpful for patients at the Skye Centre to overcome anxieties about outdoor cycling. An indoor environment on a 1:1 basis was used initially and then built up to cycling outdoors. The therapeutic relationship with the person was key.
For some patients with bariatric care needs, using a bicycle may not be suitable and trikes might offer an alternative, potentially carrying greater weight and having a more comfortable saddle. None of the OTs I spoke to had access to a trike but you could talk to a local inclusive cycle hub to see if they are able to help. Different saddles to the style usually found on bicycles are also available.
The OTs carry out a risk assessment for each person who plans to cycle. This is to manage any risks to the patient/ service user, to other patients/ service users, to staff and to the general public.
As Roger says, getting 6 people off the ward is “a big piece of work” but “it is absolutely worth it”. For Roger’s rides, it involves getting permission for each patient to leave the ward, a typed-up risk assessment for each person, ordering a taxi and getting all staff and patients to the taxi at the right time. Whilst away from the ward staff need to make sure that no-one absconds, and upon returning, making sure everyone is back and signed in. And then notes need to be written up for each patient.
The Skye Centre works closely with the security staff to make sure gates are locked when cycling was happening in the grounds. Radios were also used to make quick contact if needed.
Ignoring ride leaders, there were typically high staff/ service user ratios. For the Skye Centre these could be 1:1, with the biggest group consisting of 5 patients and 4 staff. Occasionally there can be 1 patient with 2-3 staff.
The rides were weekly, albeit weather dependent if outside. Only Roger reported the rides happening throughout the year (staffing permitting), with rain being no barrier provided a warm room was available. Snow and ice would prevent rides happening though. Jacqueline reported one wet day but this did not deter people from cycling.
Creating and resourcing the programmes
Sarah’s setting had the most developed model with sport and physical activity an important intervention in the high secure facility where patients may live for several years. Hence it is relatively well resourced. Bicycles were stored on site and maintained by staff. The person driving their programme was a Senior Rehab Instructor who was a keen cyclist and who had been at the Centre for 30 years. The Centre invests in learning and qualifications for patients which extends to the national Bikeability cycling standard and sports leadership training.
The seed for Jacqueline’s programme was a patient with a prior interest in cycling. His exploration of cycling for himself created a contact with CyclingUK, a national cycling charity, which led to a pilot for the Bretton Centre in 2017 and a further programme in 2018. Staffing difficulties meant no programme was possible for 2019 but Wakefield Five Towns Recovery College was able to work with CyclingUK that year.
One member of staff took up the Bikeability training offer from the charity. The Hospital had some cycles from a previous programme which CyclingUK serviced and brought back into use. The charity also provided 2 people for each ride, one to lead and the other to act as the backstop, making sure no-one got left behind. Jacqueline said the programme worked across both the high secure and learning difficulties wards “making a nice group” of 12 service users.
Throughout, Jacqueline found that the structure and basics of cycling such as practising road safety, “following the rules”, wearing a helmet etc. helped people to follow guidance as they could see positive outcomes, see the benefits of following rules and have an enjoyable ride.
Ward at CHSCT
The cycling programme at CHSCT started before 2008, partnering with the local council’s green spaces team and as this came to an end, another partner, the Cycling Tourists Club (CTC) (the precursor to CyclingUK) stepped in to enable its continuation. CHSCT provided funding for the CTC’s involvement with mental health awareness training provided by staff and service users and ride leadership training provided to staff and service users by the CTC. The programme has managed to operate on a shoestring, with cycles bought from a £5k bid to a charity and repairs done by a local cycle training co-op in exchange for loan of the cycles for trainees. Council hire rates for a private room adjacent to the park where they cycled increased so a cheaper alternative was found. An experienced cycle trainer volunteered weekly for many years. The CHSCT ward pays for the taxi to take people to and from the ward each week.
These interviews with 3 OTs across all the forensic inpatient security levels demonstrate that cycling can be a useful therapeutic intervention. With weight challenges and the engagement shown by many patients and service users, cycling may be a useful new tool to add to your existing range of interventions. The pandemic gives extra impetus to cycling as it is typically an outdoor activity which can be done in a socially distanced way. For those leaving wards for life outside, cycling can be a useful new skill and activity which, with so many local cycling groups, can help them reintegrate into the community.
I hope these ideas and experiences may encourage you introduce cycling and provide tips in persuading your managers to start up a cycle scheme. Sport England has just launched its 2021-2031 strategy and one of their aims is to reduce inequalities in physical activity – it may well be a good place to start if you are looking for funding. The Community Fund is also a good place to look.
As ever, please share any queries or useful tips you have so we can learn together and bring the joy and physical, mental and psychological benefits of cycling to more people. Happy cycling!