**5. Results and discussion**

The decrease in the gravity for the effect of water leads to a feeling of lightness, which is generally pleasant. For the same reasons, this environment is particularly suitable for mobilization and a gradual cardio-respiratory training in people with weight problems, condition

Among the benefits of the activity in the pool, we note especially the possibility of enhance movement and coordination and the feeling of psychological well-being, helpful in decreasing anxiety. To attend a swimming pool, with its rules of use, helps to take a greater care of self. In addition, being able to carry out a complex activity and learn new skills improves self-

In our Association, currently, we have only male players: fifteen people with age ranging from 21 to 57 years (older people are goalkeepers). Football is a sport that readily attracts new young users, as known and socially widespread and appreciated. In the version with 11 players, it requires good physical condition and enough breath to run across the field, as well as a certain level of technical ability. Everyone seems to have previous experience; they all had play as

In the 5-players version of the game, the field is much smaller, and the spaces are narrower, with more frequent contacts among the players; breathing capacity becomes less important, while control of the ball and quick overview of the field, teammates, and opponents becomes more important. The game is dynamic and fast, and there is the possibility of some injury due to the accidental knocks or falls; risks of accident are taken into account from the very beginning. The main problem of football is the physical contact between players, and its possible

In our team, the starting rules, shared and accepted by all, are simple and clear: to play for fun and you can win or lose; it makes no sense to get angry with you or with teammates. Teams are not fixed, but they are decided from time to time. The instructor looks after the technical aspects, while the facilitator is the guarantor of fairness in the field. If the aggressiveness increase, the facilitator gives a first call; then, if the problem persists, he stops the game and

The football team plays once a month against a representative of the Ferrara Scientific High School and participates in several tournaments in the area of Mental Health or during local

More than twenty people take part to Volley activity, males and females, aged from 27 to 60 years. This sport is easy to understand: at the basic level, people of all ages and fitness levels can participate, sometimes eventually using small adjustments, such as the stroke from inside

often associated with psychotic disorders, especially chronic.

esteem, while to take part of a group fosters communication.

children: on outdoor courts, at school or after the school.

meaning—not openly declared—of aggressive behavior.

*4.1.3. Football and 5-players football*

158 Schizophrenia Treatment - The New Facets

sends all in the locker room.

events.

the field.

*4.1.4. Volleyball*

Exercise, physical activity, sports, health, mental health, psychosis, and therapy: how do these concepts relate each other? Physical activity, health, and quality of life are closely interconnected [15]; to practice sport with friends, colleagues or family do have a positive effect increasing social asset [16]. On these issues, there is a common consensus, so that Regions and States define policies to encourage physical activity. It is also generally acknowledged the positive effect of exercise on mental health, in particular on self-esteem and mood, but it is not clear whether carry it out in the open air is a further advantage; greenspaces of high natural and heritage value seem to add an extra benefit [17].

In severe psychiatric patients, exercise seems to produce an improvement in the symptoms both positive and negative [18] and quality of life [19]; in some individuals, exercise may be a useful coping strategy for dealing with positive symptoms, such as auditory hallucinations; moreover, it seems to associate with an alleviation of negative symptoms such as depression, low self-esteem, and social withdrawal. Aerobic exercise positively affects cognitive performance in hospitalized subjects, suffering from schizophrenia or depression [20]. Physical activity in severe psychiatric disorders helps to prevent metabolic and cardiovascular diseases [21], improves the satisfaction about the body and self-esteem [22], and is used as part of a multifunctional rehabilitation treatment in schizophrenia, although the negative symptoms may hinder the program, reducing the motivation and causing dropouts [23]. The exercise of an overlearned physical skill, as biking, improves brain connectivity in patients and healthy individuals [24]. While in the review by Patel [25] on a wide range of mental disorders, the effects on schizophrenia are defined as "not known," the review of Soundy et al. [26] lists the possible benefits of sports activities in this disorder, and the Firth et al.'s review [27] concludes that a moderate to vigorous exercise for about 90 min per week has a therapeutic effect by decreasing cardiovascular risk factors and reducing the psychic symptoms.

The literature offers heterogeneous works, using a wide range of exercise (aerobic, anaerobic, sports) in different contexts (inpatients and outpatients), with fairly short follow-up times and limited samples; currently, it is not possible to generalize the results, or choose an activity over another, only according to the literature.

Physical activity, exercise, sport are they synonymous? In our opinion, they are not. Physical activity and exercise, at least how they are described in many works, pose as major goals the physical muscular mobilization and the cardio-vascular prevention. The concept of sport, in our view, is different: it means to deal freely with rules shared by all those who practice it, healthy or sick; it means trying to play technically or with a good performance, in a controlled environment, aiming to improve. It means, in team sports, interfacing with peers and with opponents and dealing with mistakes and defeats as part of the game. Finally, it means tackling success without humiliating opponents. Sports are leisure activities, strictly linked to concepts such as fun and enjoyment, which also constitute the main motivation to maintain the practice [28, 29].

Can a person with schizophrenic disorders deal with all it? If it does, may he/she encounter difficulties and advantages that can face? In summary, what are the specific therapeutic factors? The literature indicates the presence, in the schizophrenia spectrum disorders, of both neurocognitive deficits and social cognition deficits, related to each other but not overlapping. The neurocognitive deficits have a role in influencing the "functional outcome": self and interpersonal behaviors and skills for independent life; they can concern attention, short or long-term memory and the ability to solve problems. The Social Cognition concerns empathy, the ability to recognize and understand emotions and feelings of others, and also the ability to infer intentions, beliefs and desires of other people [30–32].

Cognitive deficits appear related to negative symptoms and a poor functional outcome: being able to modulate the functions of social cognition may be an important factor in determining the outcome of the disease and in promoting a full recovery [33]. Sport can be one of the strategies.

Sport can be one of the strategies to improve both neurocognitive aspects and social cognitive abilities. In this context, Corretti et al. [34] propose sports as a useful tool in every stage of the disease: pre-acute, post-acute and even chronic.

From our point of view, that of an users' association, we have no direct information on the effects of exercise or sport on the pathogenesis of schizophrenia: our intervention begins when the disease is overt, when there is already a diagnosis and a therapeutic program.

Our experience confirms some literature data: some of our athletes report that the sport has provided them some tools to better cope with symptoms as hallucinations, especially auditory: to fix the attention on other bodily perceptions, or on the current game in team sports, antagonizes hallucinations and decreases their disturbing effect. In team sports, the habit to trust others and the self-esteem improvement are effective antagonists of some delusions, particularly those of persecution.

#### **5.1. The users' point of view**

functional rehabilitation treatment in schizophrenia, although the negative symptoms may hinder the program, reducing the motivation and causing dropouts [23]. The exercise of an overlearned physical skill, as biking, improves brain connectivity in patients and healthy individuals [24]. While in the review by Patel [25] on a wide range of mental disorders, the effects on schizophrenia are defined as "not known," the review of Soundy et al. [26] lists the possible benefits of sports activities in this disorder, and the Firth et al.'s review [27] concludes that a moderate to vigorous exercise for about 90 min per week has a therapeutic effect by

The literature offers heterogeneous works, using a wide range of exercise (aerobic, anaerobic, sports) in different contexts (inpatients and outpatients), with fairly short follow-up times and limited samples; currently, it is not possible to generalize the results, or choose an activity over

Physical activity, exercise, sport are they synonymous? In our opinion, they are not. Physical activity and exercise, at least how they are described in many works, pose as major goals the physical muscular mobilization and the cardio-vascular prevention. The concept of sport, in our view, is different: it means to deal freely with rules shared by all those who practice it, healthy or sick; it means trying to play technically or with a good performance, in a controlled environment, aiming to improve. It means, in team sports, interfacing with peers and with opponents and dealing with mistakes and defeats as part of the game. Finally, it means tackling success without humiliating opponents. Sports are leisure activities, strictly linked to concepts such as fun and enjoyment, which also constitute the main motivation to maintain the practice

Can a person with schizophrenic disorders deal with all it? If it does, may he/she encounter difficulties and advantages that can face? In summary, what are the specific therapeutic factors? The literature indicates the presence, in the schizophrenia spectrum disorders, of both neurocognitive deficits and social cognition deficits, related to each other but not overlapping. The neurocognitive deficits have a role in influencing the "functional outcome": self and interpersonal behaviors and skills for independent life; they can concern attention, short or long-term memory and the ability to solve problems. The Social Cognition concerns empathy, the ability to recognize and understand emotions and feelings of others, and also the ability to

Cognitive deficits appear related to negative symptoms and a poor functional outcome: being able to modulate the functions of social cognition may be an important factor in determining the outcome of the disease and in promoting a full recovery [33]. Sport can be one of the

Sport can be one of the strategies to improve both neurocognitive aspects and social cognitive abilities. In this context, Corretti et al. [34] propose sports as a useful tool in every stage of the

From our point of view, that of an users' association, we have no direct information on the effects of exercise or sport on the pathogenesis of schizophrenia: our intervention begins when

the disease is overt, when there is already a diagnosis and a therapeutic program.

decreasing cardiovascular risk factors and reducing the psychic symptoms.

another, only according to the literature.

160 Schizophrenia Treatment - The New Facets

infer intentions, beliefs and desires of other people [30–32].

disease: pre-acute, post-acute and even chronic.

[28, 29].

strategies.

In over 15 years of sporting activities in the area of psychiatric disorders, especially schizophrenia, we have accumulated a wealth of experience. After several interviews with our users/ athletes, we would like to try to use their words to a "collective" description of their experience in the disease, and subsequently in sport.

#### *5.1.1. The experience of illness*

When you get sick of schizophrenia, the world falls upon you: everything is confused, your head is filled up with noise, you do not recognize the person you were before and even your environment; you do not know who to trust in. Above all, you do not know what is happening to you.

Family members and friends see you strange, they eventually could think that you take substances (sometimes, it is true), but the strangeness remains even when you are "clean". Some people pity you or are ashamed of you; sometimes they get angry and you get angry too. No one knows what to do.

Sooner or later you obtain a diagnosis and someone takes charge of you. Therapy begins: at least, the radio in your head lowers the volume, maybe turns off, but you have to deal with the medicines every day: now you are, first of all, a sick! Sometimes therapies bother, to find the right dose and the right drug is not always easy; sometimes you're too sedated and you look like a zombie, sometimes you get fat and bloated, or stiff and walking like a robot, or your hands and your mouth shake. Everything is treatable, but in the meantime you seem even stranger.

Your family members begin to protect you a bit too much, to treat you like when you were thirteen. Sometimes, they think you are doing it on purpose, that you spoil the situation, that you don't help yourself enough. Even to pronounce the name of the disease is very difficult: it is better to talk about "depression" or "nervous exhaustion": people can understand it. And you wish to have another illness instead of this, any: a broken leg, pneumonia, anything but that.

You start to look for the "guilty" of illness: another disease, a sentimental disappointment, a lack of work, a failure in the studies. Sometimes you think that the diagnosis is wrong, the doctor is incompetent, and "the pilgrimage of hope" begins, towards more and more wellknown and expensive doctors or faraway places, where perhaps a miracle will happen.

In all this, you become more and more passive, and more and more really depressed: ill, chronically, considered untreatable, you feel useless and you hide from previous friends and you run out of your previous life, so that no one could see how much you are changed. Only in your room you feel safe, even in the dark and with the music on headphones. Even complaining does not work: there is always someone who does that before and more of you.

Every business and social relationship loses its meaning, the sense of emptiness is spreading, it is difficult to express in words. It seems that nothing interests you, even if, within you, emotions and fears are pressing. It's hard to pay attention, to decode the expressions of others people: you search isolation so not to be injured. If in your life "before" there were plans, expectations, hopes, now, in the limbo of disease, the idea prevails that everything will always be the same, or rather will only worsen.

Sometimes we get stubborn, but then we accept to follow a therapeutic process where everything is very structured and encoded and disease-related: it continually reminds us of the disease. There is not much room for fun or for personal initiatives, but then, when we have to go outside in real - not protected - world, there we must to walk alone.

#### *5.1.2. The experience in sports*

Soft gymnastic is often considered mostly as exercise, whereas all other activities are considered and lived as sports. All interviewed user-athletes expressed a positive opinion: they are happy to play sports and think it is a useful tool for them both physically and psychologically. All users emphasize the importance of working together within a group, also in individual activities, and find a good social environment, which allowed the development of better social relationships and friendships.

The main reported benefits of gymnastics and swimming are to improve agility and muscle coordination, to reach a greater satisfaction with the own body and a feeling of well-being; in swimming, they are also enhanced by learning new skills and improve self-esteem overcoming fears. In team sports, the main positive aspects are fun and the feeling of belonging, in addition to the opportunities for tournaments. The rare reported difficulties are in football, for the management of aggressiveness. In volleyball, there is a great sense of teamwork and pride for the ability to face and overcome obstacles and the ethical and educational values of which the team is witness. There is a general demand for a more frequent activity, as a source of great personal satisfaction and good social relations.

All athletes emphasize that, when they are within the sport, they completely dismiss the sick role, and they feel only people, citizens and especially athletes. This allows them to improve their self-esteem, and even increase in value with respect to the family and the environment.

#### **5.2. The role of sport in the therapeutic project**

What needs can be met in the sport, and what are consequently the objectives? Well-being, skills, to avoid isolation, to build activities for leisure, to deal with other people, to improve self-esteem and quality of life, to acquire autonomy. The different activities offer varied opportunities and have different indications and features.

Gymnastics, for example, can be a preparatory: a good start for those who do not move since a long time and have to learn to well perceive their body. It is a good motivation to leave the house, and does not require an excessive involvement in social relations, although it provides the opportunity. For people who continue to practice, it is a useful tool for physical well-being, posture, equilibrium, self-knowledge and anxiety management.

you run out of your previous life, so that no one could see how much you are changed. Only in your room you feel safe, even in the dark and with the music on headphones. Even complaining does not work: there is always someone who does that before and more of you.

Every business and social relationship loses its meaning, the sense of emptiness is spreading, it is difficult to express in words. It seems that nothing interests you, even if, within you, emotions and fears are pressing. It's hard to pay attention, to decode the expressions of others people: you search isolation so not to be injured. If in your life "before" there were plans, expectations, hopes, now, in the limbo of disease, the idea prevails that everything will always

Sometimes we get stubborn, but then we accept to follow a therapeutic process where everything is very structured and encoded and disease-related: it continually reminds us of the disease. There is not much room for fun or for personal initiatives, but then, when we have

Soft gymnastic is often considered mostly as exercise, whereas all other activities are considered and lived as sports. All interviewed user-athletes expressed a positive opinion: they are happy to play sports and think it is a useful tool for them both physically and psychologically. All users emphasize the importance of working together within a group, also in individual activities, and find a good social environment, which allowed the development of better social

The main reported benefits of gymnastics and swimming are to improve agility and muscle coordination, to reach a greater satisfaction with the own body and a feeling of well-being; in swimming, they are also enhanced by learning new skills and improve self-esteem overcoming fears. In team sports, the main positive aspects are fun and the feeling of belonging, in addition to the opportunities for tournaments. The rare reported difficulties are in football, for the management of aggressiveness. In volleyball, there is a great sense of teamwork and pride for the ability to face and overcome obstacles and the ethical and educational values of which the team is witness. There is a general demand for a more frequent activity, as a source of great

All athletes emphasize that, when they are within the sport, they completely dismiss the sick role, and they feel only people, citizens and especially athletes. This allows them to improve their self-esteem, and even increase in value with respect to the family and the environment.

What needs can be met in the sport, and what are consequently the objectives? Well-being, skills, to avoid isolation, to build activities for leisure, to deal with other people, to improve self-esteem and quality of life, to acquire autonomy. The different activities offer varied

to go outside in real - not protected - world, there we must to walk alone.

be the same, or rather will only worsen.

*5.1.2. The experience in sports*

162 Schizophrenia Treatment - The New Facets

relationships and friendships.

personal satisfaction and good social relations.

**5.2. The role of sport in the therapeutic project**

opportunities and have different indications and features.

In swimming, the more specific aspects are weightless and floating: it should be interesting a further investigation about the specific effects of various bodily perceptions in the aquatic environment and their effect on body image and on perception system in general, so often impaired in schizophrenia. The acquisition of new skills and the achievement of objectives increase self-esteem, while the informal moments can provide a "play area" that allows exercising relational skills.

Football, the most popular sport in the country, both as a practice and as interest of individuals and the media, is also the one who, in the literature, seems to receive particular attention as a therapeutic rehabilitative tool. Battaglia et al. [35] studies football as an additional treatment in schizophrenia, and Masala et al. [36] describes a training protocol for football in this syndrome. Football, however, forces us to reflect on the significance of sport: it affects huge economic interest; the overpaid players, very popular, can convey positive social values but also negative. Some famous players often express in the field behaviors that would be considered highly symptomatic of mental disorder, off the field. Intolerant, provocative, threatening, aggressive, simulators; in the face of all this, they are not strongly discouraged, recalled or punished. Admonitions, expulsions and disqualifications, but then they come back and behave exactly the same way. There are matches that look like gladiator fights: faults, yellow cards, expulsions and all players exaggerate the effects of contrasts; in the meanwhile, speakers repeatedly define the game with adjectives like "hard," "aggressive," "male," all presented as positive and praiseworthy. Some fans, then, go to see football as if they were going to a battle: framed in organized groups, often armed with assault weapons, ready to destroy "the enemy" and everything they find on their way.

How can we reconcile these dis-dominant values with a sport practiced in view of psychiatric rehabilitation, with ethical and educational values? It is not always easy: there is a conflict. Almost all football teams we know were faced with this difficulty: some of them have found strategies to deal with it, others (especially ones inside the Psychiatric Services) preferred to channel the energies on other sports. We are however convinced that aggressiveness challenge can be addressed and overcome. That indeed is one of the most important goals of our activity: to learn how to deal with our and others' aggressiveness and overcome it. When we play in schools, one of our goals, in addition to combating the stigma, is to give a good example of an ethical and educational way to play the game of football.

In his very interesting and documented work, Carboni [37] defines the football as "a cognitive gym" useful to reach psychosocial health goals. For us, this happens especially with the volleyball, the sport that gives us most satisfaction, the one where you go to training half an hour before, and later you stay there chatting, joking, and making plans with your playmates and friends. It is our "cognitive fitness," this sport easy to learn, good looking, flexible respect to the number of players, cheap because you can play almost anywhere, even in the public gardens and on the beach. Few experiences are reported in the international literature, but they all are very positive [38, 39], even in the adapted version of sitting volley [40].

The volleyball allows improving a lot of cognitive skills: attention, spatial orientation, perception and recognition of a range of situations, decision-making skills, strategy: it is a problemsolving training in a context of play, which fully satisfies the Rasmussen general pattern of human activity [41].

"Was I wrong?" "Have the others been better or smarter than us?" "No problem, try again and see if it works, with a new strategy, or even the same as before, but better applied." It is no coincidence that the tradition of the game suggests to newly serve the player who has made a mistake, in order to give him/her the opportunity to rebuild and regain confidence. Point after point, play after play, self-esteem and ability to cope with the emotions grow together with the sense of the group-team. The players reflect one each other as in a mirror; following the mirror neurons theory [42], this means to communicate and to understand each other better and better. Meanwhile, people get used to work in an organized way, to come out from the isolation and to look around: it really means a training for life.

#### **5.3. Outcomes**

#### *5.3.1. How is effectiveness measured?*

A first indicator may be the number of hospitalizations: people practicing physical and sport activities require fewer hospitalizations than when they were inactive; some people decreased from 4 to 5 annual admissions to one or none. During the past year, in the group of users athletes there were only four admissions: one in the ward for acute symptoms, which lasted 2 weeks, and three, in three different people, in facilities for intensive rehabilitation programs.

A second indicator may be the adhesion to the treatment in general and, in particular, to sport classes. We do not remember, in the last 5 years, the necessity of Compulsory Admissions in people who attend sports groups; in our opinion, this means that users become more aware of their own care and they are more participating and reliable in applying it. The drop-out in sport activity is rare, usually due to external causes: family burdens, work activities, physical illness or injury. Often the injured or convalescent athletes will participate to the gym classes, to cheer their friends and even to play a useful role as "external" observers.

A third indicator is the user-athletes satisfaction and their families: sport activity is very appreciated by the family for the promotion of personal autonomy, independence and for its socializing value.

Even high school students really appreciate the opportunity to play against our teams, and their teachers feel these activities as very qualifying and deeply educational.

An external observation is provided by the interviewed referees: they all highlight the fair play of MHD teams. Furthermore, they describe a feature that makes us very happy: they knew nothing, before, of mental disorders, they expected to referee matches of very low level, and they were pleasantly surprised to find a good knowledge of the rules, a decent technical level, a pleasant game, surrounded by a great enthusiasm.

#### *5.3.2. Quality of life*

gardens and on the beach. Few experiences are reported in the international literature, but they

The volleyball allows improving a lot of cognitive skills: attention, spatial orientation, perception and recognition of a range of situations, decision-making skills, strategy: it is a problemsolving training in a context of play, which fully satisfies the Rasmussen general pattern of

"Was I wrong?" "Have the others been better or smarter than us?" "No problem, try again and see if it works, with a new strategy, or even the same as before, but better applied." It is no coincidence that the tradition of the game suggests to newly serve the player who has made a mistake, in order to give him/her the opportunity to rebuild and regain confidence. Point after point, play after play, self-esteem and ability to cope with the emotions grow together with the sense of the group-team. The players reflect one each other as in a mirror; following the mirror neurons theory [42], this means to communicate and to understand each other better and better. Meanwhile, people get used to work in an organized way, to come out from the isolation and

A first indicator may be the number of hospitalizations: people practicing physical and sport activities require fewer hospitalizations than when they were inactive; some people decreased from 4 to 5 annual admissions to one or none. During the past year, in the group of users athletes there were only four admissions: one in the ward for acute symptoms, which lasted 2 weeks, and three, in three different people, in facilities for intensive rehabilitation programs.

A second indicator may be the adhesion to the treatment in general and, in particular, to sport classes. We do not remember, in the last 5 years, the necessity of Compulsory Admissions in people who attend sports groups; in our opinion, this means that users become more aware of their own care and they are more participating and reliable in applying it. The drop-out in sport activity is rare, usually due to external causes: family burdens, work activities, physical illness or injury. Often the injured or convalescent athletes will participate to the gym classes,

A third indicator is the user-athletes satisfaction and their families: sport activity is very appreciated by the family for the promotion of personal autonomy, independence and for its

Even high school students really appreciate the opportunity to play against our teams, and

An external observation is provided by the interviewed referees: they all highlight the fair play of MHD teams. Furthermore, they describe a feature that makes us very happy: they knew nothing, before, of mental disorders, they expected to referee matches of very low level, and

to cheer their friends and even to play a useful role as "external" observers.

their teachers feel these activities as very qualifying and deeply educational.

all are very positive [38, 39], even in the adapted version of sitting volley [40].

human activity [41].

164 Schizophrenia Treatment - The New Facets

**5.3. Outcomes**

socializing value.

to look around: it really means a training for life.

*5.3.1. How is effectiveness measured?*

The perceived quality of life was measured in the group of users athletes, 51 people, 30 males and 21 females using the WHOQOL-brief scale 26 items. All schedules are valid.

The overall quality of life is perceived in all cases as "good" or "very good" and only 12% of people are dissatisfied with their own health.

The level of physical perceived health is high: the majority of cases declare that they feel well, without pain, full of energy, able to cope with their daily activities; many people have a job. They need some treatment, but they don't consider this as an impairment.

Psychological health level is high, too: only 6 people are unhappy about their appearance, they are mainly self-satisfied and able to concentrate. The majority think that life is pleasant and meaningful. None of the athletes-users felt always or often discouraged, in the last few months.

Information, mobility, safe and security, place where they live and transport does not show any kind of dissatisfaction or problem, but the financial resources are very limited, just enough to cover the needs, in 65% of cases; it is difficult to engage in leisure activities for a lack of money and time.

They are very satisfied for the support received from friends, quite satisfied about their personal relationships, often unsatisfied in the sexual activities area.

Overall, the perceived Quality of Life looks good and it is very significant that it is also good in the Domains most at risk in schizophrenia: Social Relationships and Psychological Aspects.
