**4. Sport**

**3. Method**

154 Schizophrenia Treatment - The New Facets

staff.

of collaboration.

personal and relational skills or social integration.

The Mental Health treating team performs the referral to the sport activity with different objectives as to promote health and physical well-being, to motivate social participation and prevent isolation, to have recurring weekly activity, and to socialize or to promote specific

The technical aspects of training are supervised by professional coaches provided by UISP, while the weekly organization and conduction of sports activities, initiated by psychiatric workers and conducted by them for over 10 years, are since 3 years assigned to a user with specific training as a social facilitator, who is always present. The facilitator is a user who has achieved a good level of clinical stabilization and who is perceived by other users as an ally, able to understand their feelings, because he too has had experiences. At the same time, he is the referee of fairness of play in the field and guarantees the respect of sporting rules; he acts as a mediator among the athletes and acts as a liaison between them and the MHD

The psychiatric worker, belonging to the MHD semi-residential rehabilitation center, collaborates with the social facilitator for the implementation of sports activities and works together with the caring team when admitting the new users/athletes; she supervises and maintains links with MHD and regional sports groups. Facilitator and psychiatric worker together reinforce the results obtained with the sports, promote self-esteem, create the conditions allowing everyone to feel at ease and find a role in the activities. They closely cooperate in the organization and coordination of activities, as required by a specific protocol

Sports activities as part of a therapeutic rehabilitation project are currently four: at an individual level, gymnastics and swimming in the pool, and as a team, volleyball and football (5 or 11 players). To these activities take part weekly about 50 people, males and females, aged between 20 and 64 years, with different psychiatric disorders; schizophrenia represents more than half of the diagnoses. Many users/athletes practice currently more than one activity.

All sports are practiced at least once a week; in addition to this, we organize and take part to social events and regional sport meeting. At least once a month, the volleyball and soccer teams play against teams of high schools, as part of a project aiming to educate young people and fight stigma. Sport activities are subject to either external observation—by professional coaches, psychiatric worker and facilitator—and self-observation by athletes themselves. In team sports, the end of a session of training is often followed by a time of reflection, informal but very effective, where the team group examines the progress achieved and any difficulties

To gather more information, the point of view of users athletes has been audited in 2016 with individual interviews and using the World Health Organization Quality of Life (WHOQOL) brief schedule, 26 items [5], to get information about the perceived level of quality of life.

encountered, and programs the next workout or the participation in tournaments.

"Sports have the power to change the world. It has the power to inspire, the power to unite people in a way that little else does. It speaks to youth in a language they understand. Sports can create hope, where there was once only despair. It is more powerful than governments in breaking down racial barriers. It laughs in the face of all types of discrimination" said Nelson Mandela in 2000 [6].

Sport as an ideal value [7] was born in ancient Greece, where the Olympic Games were the occasion of peaceful encounter, and not confrontation, among people who recognized themselves in a common identity, while belonging to different political or social systems. During the games, conflicts were suspended, gift was exchanged, and all people had to follow common law, as the possibility of participation for all; misbehaviors were prevented or punished.

In contemporary culture, sport is a total cultural phenomenon that has transformed social customs and even the clothes; it involves everyday life context, it is magnified out of proportion by the media, and it reflects, at a different level, the same problems and contradictions of the society. It is no longer a value in itself; rather it is often a source of conflict, confrontation, and aggression.

It becomes a "value" only within an ethical and educational context, when it takes a positive social meaning and promotes the good of the community and the improvement of relations among its members [8]. The Recommendation on the European Sport for All Charter, adopted in 1992 and revised in 2001 [9] defines sport as a right for all citizens, of which the States must be guarantors; moreover, it recognizes "the diverse contributions which sport can make to personal and social development."

For people with disabilities, whether physical or mental, sports are not always easy: it is necessary to overcome resistance and personal or environmental barriers. Sometimes, one has to use devices, or even build them. Sometimes, it is necessary to adapt the rules, so that they may become accessible, to find the facilities but, above all, it is essential to find organizations available to welcome individual athletes or groups of athletes with disabilities and their needs. For isolated people this is very difficult; the presence of corporate associations, connected in a network of associations, increases the possibilities and sport opportunities.

In physical disability, injury or sensory loss is visible and obvious; in this area, sport is now universally recognized as a therapeutic, rehabilitative tool of socialization and inclusion. The high costs of devices are certainly an obstacle, but there is usually a strong motivation of the athletes, their family and social environment. Adapted Sport [10] plays an important role both at school and in leisure and free time, while the Paralympics events [11], with their large participation of athletes and public, are a powerful media instrument of sport values in conditions of disability.

In mental disability, impairment is not immediately visible, and devices are not necessary, but it is often necessary to adapt the rules of the different sports. In most cases, sports activities are carried out within the Psychiatric Services, for recreational and therapeutic purposes; for young people, there are special projects in schools, especially in high schools.

Networks of Associations promote sport at a regional level or national one: some Associations are strongly characterized in the health-psychiatric domain (i.e., ANPIS, Plural Sport Association for Social Integration); others operate in an "external" field the civil society. Among these, the UISP is the most common, but there are many others. Intellectual and Relational Disability Federation (FISDIR) is affiliated with the Paralympic Committee.

The concrete work in this area is extremely widespread, at least in Italy, with a wide range of popular sports: athletics, gymnastics, swimming, skiing, sailing, canoeing and rowing, archery, bocce, judo, tennis, table tennis, football, basketball, volleyball, and rugby. In our limited experience, we are aware of a dozen soccer teams and more than twenty volleyball teams, we have reports of various regional tournaments and even a regular UISP championship, in the Piemonte Region.

#### **4.1. Our practiced sports**

#### *4.1.1. Soft gymnastics*

Soft gymnastic was born in the seventies of the last century, as a set of activities aimed at finding a harmonious relationship with the body and the environment, through a conscious and active working attitude. It is a misleading to consider it as an application of traditional exercise in a reduced scale, for "weak" people.

Our body is very sensitive to anything that can alter its equilibrium. If one makes a pleasant experience and enjoys feelings of well-being, it will try to reproduce these feelings in an unconsciousness manner; on the contrary, bad experiences and unpleasant feelings will lead to painful muscle contractions and poor posture. Therefore, it is important to learn to feel and know every sensation coming from the body, to become aware of the movement, and to adopt personal strategies contrasting physical and psychological distress.

Anyone can enjoy soft gymnastics, regardless of age, even in non-homogeneous age groups; the perfect setting for these activities is a heated gym with a wooden or rubber silent floor, in order to favor listening and concentration. There is no need for special equipment, except for mats and small equipment, such as balls or tennis balls, which facilitate the work on the perception of the body.

Our gymnastics groups, attended by about thirty people, males and females, are held weekly and are led by a UISP teacher with special training. Each lesson lasts between 50 and 60 min and is divided into three sections: worm up, work, and cooldown. During worm up, we execute full body preparation exercises, aimed at further improvement of equilibrium, muscle tone, coordination, and proprioception. After the warm up, there is a phase in which participants stand in circle to be able to face each other. This produces a greater degree of harmony and the creation of a group in which all feel an integrative part.

Exercises and movements are taken from different techniques, all aiming to restore the psychophysical equilibrium and the harmony of the body: Eutonia, or Alexander method [12], Bertherat "anti-gymnastic"[13], Feldenkrais method [14], and Stretching.

The final phase, body relaxation, allows to reach a physical and psychological well-being. We also use music as a basis to facilitate individual expressiveness and build a body-mind feedback that generates positive reactions.

The teacher carries out both an individual and group observation, periodically evaluates eventual problems, improvements and acquisitions of skills, highlighting especially the qualitative aspects of the movement. Other objectives of soft exercise are to improve psychological well-being and ability to manage stress, to reduce anxiety, and to improve self-esteem and social integration. An important goal is also to create a positive and welcoming environment, encouraging the formation of a good group, and allowing to achieve harmony and wellbeing among all participants.

#### *4.1.2. Swimming*

are carried out within the Psychiatric Services, for recreational and therapeutic purposes; for

Networks of Associations promote sport at a regional level or national one: some Associations are strongly characterized in the health-psychiatric domain (i.e., ANPIS, Plural Sport Association for Social Integration); others operate in an "external" field the civil society. Among these, the UISP is the most common, but there are many others. Intellectual and Relational Disability

The concrete work in this area is extremely widespread, at least in Italy, with a wide range of popular sports: athletics, gymnastics, swimming, skiing, sailing, canoeing and rowing, archery, bocce, judo, tennis, table tennis, football, basketball, volleyball, and rugby. In our limited experience, we are aware of a dozen soccer teams and more than twenty volleyball teams, we have reports of various regional tournaments and even a regular UISP championship, in the

Soft gymnastic was born in the seventies of the last century, as a set of activities aimed at finding a harmonious relationship with the body and the environment, through a conscious and active working attitude. It is a misleading to consider it as an application of traditional exercise in a

Our body is very sensitive to anything that can alter its equilibrium. If one makes a pleasant experience and enjoys feelings of well-being, it will try to reproduce these feelings in an unconsciousness manner; on the contrary, bad experiences and unpleasant feelings will lead to painful muscle contractions and poor posture. Therefore, it is important to learn to feel and know every sensation coming from the body, to become aware of the movement, and to adopt

Anyone can enjoy soft gymnastics, regardless of age, even in non-homogeneous age groups; the perfect setting for these activities is a heated gym with a wooden or rubber silent floor, in order to favor listening and concentration. There is no need for special equipment, except for mats and small equipment, such as balls or tennis balls, which facilitate the work on the

Our gymnastics groups, attended by about thirty people, males and females, are held weekly and are led by a UISP teacher with special training. Each lesson lasts between 50 and 60 min and is divided into three sections: worm up, work, and cooldown. During worm up, we execute full body preparation exercises, aimed at further improvement of equilibrium, muscle tone, coordination, and proprioception. After the warm up, there is a phase in which participants stand in circle to be able to face each other. This produces a greater degree of harmony and the

young people, there are special projects in schools, especially in high schools.

Federation (FISDIR) is affiliated with the Paralympic Committee.

personal strategies contrasting physical and psychological distress.

creation of a group in which all feel an integrative part.

Piemonte Region.

**4.1. Our practiced sports**

156 Schizophrenia Treatment - The New Facets

reduced scale, for "weak" people.

*4.1.1. Soft gymnastics*

perception of the body.

In swimming, the main factor is water, with its physical characteristics (hydrostatic pressure, temperature, buoyancy) that interacts with the body. Our classes, involving 12 people, males and females, are conducted on a weekly basis in an indoor pool, 1.30 m deep, under the guidance of a professional UISP instructor. The sessions include a technical phase, in groups, related to different swimming styles (crawl, backstroke, breaststroke), and a phase of free swimming for those who have already acquired skills. Also diving activities are carried out in group, in a circle, and so is final relaxation, using schemes like the horse water or the fish star.

A preliminary difficulty, for some people, is made up of having to undress, and show a body that does not meet the prevailing standards of beauty, or a shape which is different from your "ideal" body, that of youth or before illness: leaner, more muscular, straighter, maybe more tanned. Some women have implemented an effective strategy to deal with this problem, wearing different costumes, such as those for diving.

To get in the pool is, for some people, an already known experience, mostly pleasant: they are good swimmers and they are happy to be in the water. For others, it's a new experience and it can also be scary for the loss of contact with the earth, for fear of sinking, for the difficulty of letting go to support of water, and for the loss of the usual boundaries.

Once entered in the water, the cutaneous perceptions change: most of the body surface is no longer surrounded from the air, but by a liquid, which exerts a pressure on the skin, and which has a temperature that may be important for the purposes of the first adaptation.

People must also deal with the effect of buoyancy on every single human body, depending on the shape, the weight and body density: some parts tend to float and others, with a greater relative weight, tend to sink. Flotation entails a different equilibrium, which will vary with the slightest movement, inducing continuous adaptations in the proprioceptive perception system. This changes completely the entire movement control and coordination, according to new parameters, not usual in a "dry" environment.

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 often associated with psychotic disorders, especially chronic.

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

#### *4.1.3. Football and 5-players football*

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

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 meaning—not openly declared—of aggressive behavior.

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 sends all in the locker room.

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 events.

#### *4.1.4. Volleyball*

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 the field.

Volley promotes correct behavior in the field and the respect of the opponent to the point that the team who protests or offends the referee loses the point. It has also the great advantage of keeping teams separate, each in own field, with a net between the two teams and the two halves of the field. The net allows to see the opposing team, but there is no body contact; only the ball can pass from one field to the other, always in the air, in flight; who let it drop loses the point.

The error is a normal occurrence in the course of the game: the team who makes fewer mistakes wins the match. It is an exquisitely collaborative game: all players bring a contribution. To know the playmates and their characteristics increase the chances to play well and successfully. The continuous rotation of positions, then, allows to experience different points of view of the field and to adjust to different actions companions.

Many factors come into play, such as structure and physical fitness, technical skills, tactical sense, spatial orientation, ability to predict the moves of others, ability to communicate, and understand each other and help each other in the field.

In our team, all players participate in the game: when there are more people than 12—the sum of two teams' players—we use to change a player at the time of stroke, thus allowing everyone to play. Who is not in the field at that time participates as audience. Every successful action is applauded, and people with less technical skills are strongly encouraged and applauded when they manage to keep the ball in play.

The Volleyball team regularly plays with teams of the city's high schools and participates in several tournaments during the year. In recent time, we evolved to a more engaging level of play, attending to the UISP National Championship.
