Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Nutrition and Exercise for Wellness and Recovery, NU-R, a Health Activation Intervention. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers, and one nursing continuing professional development contact hour. Credit for participating in today's webinar will be available until June 12, 2023. Next slide. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. And please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for question and answer. Next slide. And now I'd like to introduce you to the faculty for today's webinar, Dr. Kutena Brown. Dr. Brown is a professor for Midwestern University's Occupational Therapy Program. Her research has focused on sensory processing, cognition, wellness, and community living for individuals with serious mental illness. She developed NU-R, a weight loss program for individuals with serious mental illness, in collaboration with the Center for Psychiatric Research at the University of Illinois, Chicago. Dr. Brown's current research includes a study examining sensory processing preferences in people with substance use conditions and the development of a measure of interception. Dr. Brown, thank you so much for joining us today. Thank you. I'm happy to be here. I'd like to acknowledge my collaborators, Judith Cook, who directs the Center on Mental Health Services Research and Policy at the University of Illinois in Chicago, where this project originated. And also Jessica Janikis and Pamela Steichman, who are instrumental in managing the research associated with NU-R. We have no disclosures for the subject matter of this presentation. Today we'll be providing you with some background information on why we thought NU-R was important, but more importantly, we'll be giving you resources and information that you can use so that you will be able to implement NU-R in your own practice setting. People with serious mental illness experience many chronic illnesses, such as diabetes, high blood pressure, heart disease, and asthma, but they often do not receive adequate healthcare to prevent or manage these conditions. NU-R is one of many initiatives to improve the physical health of people with serious mental illness. So why did I think it was important to develop a manualized wellness intervention for people with serious mental illness? Back when I was at the University of Kansas, I was doing a lot of work at a very innovative community support program. We were all noticing that people were dying who shouldn't be. People in their 40s and 50s were dying of heart attacks. An important study in 2006 found that people with schizophrenia in the U.S. died 25 years earlier than people in the general population. An update of this important study found that there continues to be a reduction in life expectancy of people with schizophrenia with as much as 25 years of life lost. The new research also finds that the reduction in lifespan is not just in the U.S., but it's a worldwide phenomenon. It is cardiovascular disease and not a mental health issue like suicide that is the leading cause of death in people with serious mental illness. And metabolic syndrome, which includes diabetes and obesity, is exceedingly high. More recently, but unfortunately not unexpectedly, we've seen an increased incidence and mortality related to COVID in people with serious mental illness. As we know, most people with serious mental illness live in poverty and being poor is associated with an increase in chronic conditions. In addition, research with people with serious mental illness indicates they have poor diets and tend to be very sedentary. In my own research, in an early study that we did, we collected detailed diet on participants in the study and found that most people only ate one serving of fruits and vegetables a day and the most common vegetable that they ate was French fries. Not necessarily a very healthy choice. We believe that the concept of obesogenic environments is an important one when trying to help people be healthier and lose weight. And later I will discuss how we think environments influenced the outcomes of our study. Generally speaking, an obesogenic environment is one that encourages weight gain. For example, environments where high calorie foods are readily accessible, but fruits and vegetables are not. Or when people don't feel like they can walk safely in their neighborhoods. Or if at home or work, people are bringing in donuts or other unhealthy foods for treats. An additional obesogenic factor for people with serious mental illness is the side effect of psychiatric medications. And all psychiatric medications can cause weight gain with Cyprexa and Clozaril being especially likely to cause people to gain weight. However, this makes it even more important that we provide interventions to prevent or reduce weight gain for people with serious mental illness. And later on, I'll talk a little bit about how our program did not have a differential effect depending on medications and suggesting that weight loss is possible for people that are taking medications that do cause weight gain. The purpose of the new R program was to develop something that would be easy to implement in the settings where most people with serious mental illness receive their services. One of the ways that we went about doing that was to make sure that we created participant and leader manuals that were very detailed, providing step-by-step instructions for leading the program. This is an important slide because the link to those manuals is available here. So you can access the participant and leader manuals at this website and they are free of charge. The program can be provided by peers and other staff. The program was informed by another weight loss program that I developed prior to new R that I'll talk a little bit more about, but that was a 12-month program. And instead, new R is an eight-week program, again, making it easier to implement for people in typical community settings. So previous to new R, I had NIMH funding to develop a weight loss program with colleagues at the University of Kansas Medical Center that we called RENEW, which stands for Recovering Energy Through Nutrition and Exercise for Weight Loss. It was an intensive one-year program that included meal replacements during the first three months. So although we had some positive outcomes associated with this intervention, it was not easily implementable in typical community settings. So we took lessons that we learned from RENEW, along with talking to additional experts listed here to develop new R. And these experts were people who had also developed weight loss programs or some other kind of wellness programming. And many of the people in this list also have a lived experience with serious mental illness. I interviewed all of these folks and put together their feedback to identify the major themes or suggestions that they made for us. And we used this information to develop new R. This slide illustrates the results of the RENEW study. And even though I'm not talking about RENEW, there's a theme from this study that's going to carry through with new R that I want to emphasize. So what you see is in cohort one and three, we had really impressive results with weight loss with people at the middle period losing as much as an average of 10 or close to 15 pounds. However, when you look at the data for sites two and four, we did not have good results. And in fact, people were gaining weight by the end of that study period. So we tried to look at the demographics in each of those sites to see if that might give us a clue as to why there were differences. And we didn't find any differences in terms of diagnoses at that site, at the different sites, gender, race, or medications. In fact, when we did a separate analysis comparing people that took medications with either a high, moderate, or low risk for weight gain, and we found no difference among our participants indicating that those that were taking even the high-risk medications for weight gain were benefiting from the program as much as those taking medications with minimal risk. So we started thinking about what was the difference between those sites. And from the people that led the groups at the different settings, they were able to say that cohorts one and three had already initiated wellness programming. They had things like wrap plans, walking programs, and a general culture that embraced wellness while cohorts two and four did not. The message here is that we think it's important that the setting where you implement NU-R is one that promotes wellness in ways that go beyond just the eight setting class. For example, when we first implemented renew at the cohort one site, the site was willing to provide participants with a healthier lunch option. They typically provided lunch for people that attended that setting and agreed to create a healthier lunch option, not just for our participants, but anyone that wanted it. However, the participants felt that they would be tempted by the regular choice. And so they were able to work it out with the site that they could receive both that healthier option and eat it in their own space. Our program is based theoretically on three different frameworks, skills training principles, cognitive behavioral strategies, and environmental support. I will explain in greater detail how we use these theories to create strategies for NU-R. So first with skills training, some of the feedback we got from renew participants is that they sometimes felt overwhelmed with the amount of information. So we attempted to address this by distilling the message, identifying what was most important for participants to learn and then provide lots of opportunities for repetition and application of what we're teaching while also making it specific to the individual and their situation. So we would present information, give people opportunities to apply it in different ways in the classroom and then have ways for them to use that information when they went home. In addition, we found that it was important to develop self-efficacy as many of our participants didn't believe that they were capable of making lifestyle changes. In the earlier renew program, we often talked about barriers to change and we ended up deciding that this was counterproductive because it tended to draw attention to what makes being healthy hard to do instead of focusing on ways to go about making a change. So in our sessions, each class ends with a success story and these success stories seem to be a powerful message. These stories were written by someone in recovery that has found success in adopting healthy behaviors. The story is read by someone in the group and then we have a discussion around it. The success stories, along with other things that we did in the sessions, help people believe that they could also make changes in their own lives. Again, and this will be a theme I'll bring up repeatedly, we really emphasize the importance of environmental support. So considering the environment and what might you do to create changes before or during the implementation of new R. So for example, for an individual in the group who lives with other family members, we would occasionally speak to family members about making changes at home. Another time we were able to enlist a nearby community college as a place where our participants could exercise by using their outdoor track and getting free access to their gym. So each session is structured the same way. We start with a quote to create a positive attitude towards change. We introduce content for that day and then provide an active learning component related to whatever the session's topic is. The group then exercises together and that's followed by goal setting. So each person in the group sets a very specific and achievable weekly goal. Then we emphasize what to work on that week when they're not in the session. And finally, at the end, we read the success story. So this slide illustrates the content or focus of each of the eight sessions. And I'm going to speak briefly about each one. The first session is titled, I can make a change. And at this session, we start the process of developing self-efficacy. Here's an example of one of the activities that comes from the participant manual. We talk about the importance of waking up at a reasonable hour and having a plan for the day. So the person can look forward to that day. And one of the themes that you'll see throughout the program is this idea of being intentional or having a plan for different aspects of the day and how to be healthier in what you're doing. The next session is the ABCs of healthier eating. And in this session, we place a big emphasis on adding more fruits and vegetables. We use the MyPlate image to help teach this concept. In this third session, we learn how to read food labels and strategies for reducing portion sizes. Our participants often talk about how helpful this particular session is and how it is one of the strategies they continue to use outside of the program. We bring in lots of real-life examples of foods to practice with so that everyone in the group has an opportunity to talk about reading food labels. The next session is Let's Get Moving. In this session, we focus on the importance of physical activity. Every session includes exercise, but I also wanted to let you know that we have created exercise videos that are available online for your use. We included people in recovery in the videos, and there's a different video that you can use for each of the eight weeks. This one is for the dance workout. There's one that focuses on cardiovascular exercises, one that is more about stretching and yoga, and another one that emphasizes strength training. You can use these videos in your sessions, or you create your own exercise plan. It can be as simple as going outside for a walk or doing a walk indoors if you have space to do that. Another easy strategy that I've used is to get your group in a circle and play some music, going around the circle and having each participant lead a different exercise. We typically do this for about 20 to 30 minutes. However, in this particular session where physical activity is the emphasis, we talk about the importance of physical activity, not just for physical health, but also its impact on mental health. We talk about how people can incorporate physical activity into their daily life. Okay, and the next session is eating out. This session focuses on strategies for eating healthy when going to a restaurant. We teach some of these strategies by using the Calorie King. There's a hard copy or a paperback book that you can buy, or there's a free app that's available that provides nutrition information on a wide range of chain restaurants. We have participants choose a restaurant and meal that they typically get when they go out to eat, and then have them try to make a healthier choice using the information from the book or the app. In the next session, we talk about meal planning and thrifty shopping. So, we're applying that idea of intentionality to making a plan for what you're going to eat for an entire week and how to go about getting the foods that you would need to do that, and then how to go about getting the foods that you would need to do that. In this session, participants actually create their meal plan for the next week. We ask them to take the meal plan home with them to use it when they go grocery shopping, and then to come back with the meal plan to the next session and give us a report on how they did. One strategy we teach related to shopping is shopping around the perimeter of the store where they're more likely to find fruits and vegetables. In the seventh session, we focus on simple meal preparation at home. It can be something as easy as making a sandwich or heating up a can of soup, but again, here's an example of how we try to individualize all of our sessions. We ask the person to identify something that they eat at home. So, something that would be likely that they would prepare, and they would write out the ingredients for how they typically make that meal, and then we would ask them to take out the ingredients for how they typically make that meal, and then we would ask them to think about how they could modify that meal to be healthier. And then our final session is a celebration, but we also discuss how participants can use the information that they learned in NU-R to stay on track. The participants think about the strategies that were useful to them. Something that's important to understand about NU-R is that our program is not about following a specific diet or rigid plans for what to eat or what exercises to do each day. Instead, we're offering a lot of strategies that we ask participants to try out during these eight weeks, and then determine what strategies make the most sense for them in their situation and their lives, and what they want to adopt. So, in this last session, we are specifically asking them to think of three things that they've made, changes they've already are working towards, and then we kind of problem solve how they can maintain those changes in their life. I should also, I'd like to also just point out here that sometimes we have participants that are not quite ready to make a change, but still really benefit from the information that they're learning in the session. We had a participant once in a group that I was running that really didn't adopt any of the changes, but was very active in all the sessions, asked lots of questions, and a couple months later came to us and had started then implementing the program and was actually very successful in her weight loss goals. So, after we created the program and tested it out with a pilot study, the University of Illinois, Chicago, received a NIDILRR grant where we were able to fund a randomized control trial of the new ARP program. It was conducted at five different settings in Illinois with a total of 107 participants. These are the areas where the intervention group improved more than the control, and they include improvements in perceived competence, but also engagement in healthy lifestyle practices, particularly those related to nutrition and spirituality, meaning participants in the intervention group were making changes to what they were eating, and in terms of spirituality, a lot of the questions on that scale relate to things like feeling as if your life has meaning, feeling like you're growing, and so we feel like that represents, again, making changes towards positive life goals. Yet, unfortunately, what you see is there was no significant difference for weight loss when we compared all the participants in the intervention group to all the participants in the control group. However, like with the RENEW study, we decided to look again to see if there were differences at the intervention sites. So, this is the trajectory of weight loss at the five different sites. The follow-up ends up being a six-month follow-up. So, again, what we found were there were sites we thought of as responder sites, or sites where people were losing weight, and then other sites where people were tending to gain weight. So, we divided our participants into a responder and non-responder sites, and here you can see the difference that there was a significant difference. People in our new R group were tending to lose weight while people in the non-responder sites were not. I'd also like to just point out that, like with all studies like this, we're looking at averages, and in each cohort, we often have individuals that really respond strongly to the program. We've had people lose much more weight than the average, so there might be individuals within a particular group that are losing 20 or more pounds. But, again, finding this kind of pattern in both RENEW and in the new R program leads us to believe that the environment in which we're implementing the site is very important. And what I'd like to sort of end with is things to emphasize or consider when you are implementing new R. So, I hope that some of you have found this interesting enough that you might want to try it out. And just here are some words of wisdom or things that we think are important. So, the theme of being intentional, the importance of making small changes, and finally creating an environment that supports change. And I'm going to speak to each of these individually. So, a major theme throughout the program, as I've mentioned, is being intentional. You can also think of this as being mindful or simply the idea of making a plan. We apply this theme to whatever is the topic of each session. If I use the example of eating out again in this session, we would encourage people to think about what the menu ahead of time before going out to eat and making a plan for what they're going to eat before getting to the restaurant. And believing that you can make that difference. I think intentionality is strongly associated with the idea of self-efficacy. And when people believe that they can do it, they tend to have more success in meeting their weight loss goals. Another point that I probably haven't emphasized as much is the importance of making small changes. Oftentimes, when people start NU-R, they have kind of lofty goals of how much weight they want to lose or what kind of exercise program they're going to adopt. And we try to emphasize the importance of making small changes because small changes are more likely to be achievable. And we also know that when people lose weight gradually, they're more likely to maintain that weight loss. We spend a lot of time in the goal setting part of the session helping people write their own individualized goal for the week. And then we help them modify those goals as the program goes on. For this population, sometimes I found that making a small change can have a big impact. And again, if we explore individually where a participant can make a change, we can sometimes make those big differences. For example, in one of the times I was running the program, we had a gentleman that was feeling kind of frustrated that he wasn't achieving his goals. And we spent some extra time with him talking about his diet and maybe what were places where he could try to set an achievable goal. When talking about it with him, we learned that every day he carried around with him a huge glass of iced tea that he refilled as needed. And we found out that he was adding large amounts of sugar to each glass. He was willing to set a goal around this. And we started very small by reducing the amount of sugar in his tea. And eventually with this process, he eventually switched from tea to mostly drinking water on his own without our having to prompt that change. And then finally, the idea of creating an environment that supports change, something that I have mentioned often, but I'd like to give you some more examples here. One of the things that we would encourage you to do is to think about what kinds of wellness programming you might offer in addition to NU-R or to re-offer NU-R. In some of the settings that have adopted the program, they offer it on a regular basis and allow participants to retake the class. So sometimes people just need additional support or by taking the class again, they may find a different strategy that they want to really focus on. So that's one option. Wellness recovery action planning is a good complement to NU-R and can really be compatible with the goal setting piece of NU-R. Walking groups or healthy cooking groups or other kinds of specific targeting programs are also ideas that you might offer in conjunction or after offering NU-R. Another idea that I became familiar with when looking at the literature is this idea of nudge interventions. And nudge interventions are things that you do to the environment that allows people to have a choice. They can still decide what they actually want to do, but the nudge influences them to act in a healthier way. So some examples of nudge interventions might be peers and staff modeling healthy behaviors. Something that I've not implemented, but an idea that I think makes sense and others have asked about is maybe having staff taking the new R-Class at the same time that other members of the setting where you're providing the service are, so that they can kind of conjointly be working on the same goals and be supporting each other. Thinking about what foods are available in your setting or in people's homes and looking at ways that you can change what foods are most convenient. Having calorie counts available on menus often helps people make healthier choices. I know that's something that, if I'm at a fast food restaurant and see that on the menu, it often influences my own choices or having reminders or signs to encourage physical activity, like using the stairs or taking a walk. Here's the bibliography and some other articles you might go to to get more information that we used in implementing and understanding our program. So thank you for your attention. Thank you so much, Dr. Brown. That was a really valuable presentation, jam-packed full of things that will help us actually implement programs at the place that we work. So I really appreciate that. Before I shift into the questions and answers, and we do have some, so I'm excited about that, please enter your questions and answers and I will get to them in one minute. I wanna take a moment and let our audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org forward slash app. So now I thought we could go to some of the questions, and of course I have some of my own as well because it was just a really, you know, made me think a lot. But let me start with some of the questions that our audience has asked. And a couple of these that have come in are really about tailoring for specific groups. So one individual said, you know, this is super exciting. Thank you so much for sharing new art. Do you have any tips for using or adapting new art with youth or young adults? Is there anything specific there? Yeah, you know, I think that one of the things that might be easier to implement is the physical activity. I think that that's one of the parts of our program that we've struggled with getting people to be more physically active. And sometimes with young people, they are more willing to do or more interested in doing that. But instead of doing exercises, you might play games that are, you know, popular basketball or sometimes we've set up obstacle courses or so you might think differently about how you did that physical activity piece. You might also need to think about involving the parents more and maybe including the parents early on in terms of what food they might have in the house or letting the parents at least know what their youth are gonna be learning about so that they can support their children. Yeah, I think those are really good tips. I remember we did a nutrition and wellness program when I worked in the VA and it was an older adult population and we used some old Dancing to the Oldies songs. And so you can adjust the music based on kind of your audience. I love that idea of dancing because it frees them up in so many ways in the group and people get to know each other better and they can have a good laugh and they kind of enjoy coming. So I love the fact that you have those YouTube videos around dancing and I think that's a great recommendation. So flip side of that, someone else wrote in and said, how do you work with people with mobility issues such as walkers, wheelchairs, unable to vigorously exercise and have no family support, only community support? So any tips for that group, kind of the other end of the spectrum? Well, in terms of the physical activity in, it didn't illustrate this in the example that we had pulled up there, but in many of the exercises, we do have somebody sitting in a chair. So we have modified the exercises that we're doing towards doing chair exercises. And the success stories sometimes speak to that as well. I can remember one of the success stories, one of the people talks about how they use the commercials when they're watching TV as a time to exercise and they do that from their chair and they talk about the arm and leg exercises that they can do. So I think really one of the messages that we're trying to give people is that regardless of your situation, moving more, making small changes in what you eat is possible and those small changes can really make a difference. You know, one of the things I remember learning when I was doing one of these programs was like as a clinician, was don't ever assume you know what they're eating, right? Or that they do or don't know. A lot of people didn't have a lot of education or models growing up on how to cook different things. And I remember there was, I was naive beginning of my career and I was doing all these weight loss programs and I would get to like session 12 and someone would say to me, I know you keep talking about fish but I have no idea how to buy fish or how to cook it. And I'd been talking about it for weeks, just assuming everybody knew how to cook a piece of fish or pick out a piece of fish. And so I think it's, you know, I love the fact that you went through all of those pieces like looking at the labels and you know, how do you pick out this? And I think just as clinicians, we have to just remember not to assume anything, just always ask, always kind of get them to talk to each other about how to use spices and how to, you know, all those different things. Yeah, you know, one group that I was running on their own, they decided that they wanted to have like a show and tell of healthy snacks. So different people signed up for different weeks and they would bring something that they thought was a good choice. So something that was inexpensive and easy, like, you know, wasn't hard to prepare. And so that was really helpful. Because again, they often were thinking of things that wouldn't have come to mind for me. Right, right. The other thing I remember, again, kind of when I worked at the VA, they were kind of sharing tips about increasing exercise because it was, you know, it's very hard. A lot of the, a lot of, a lot of many of us are very sedentary and they were saying things like, well, you know, I just started to get off the bus one stop earlier before home, you know, or I just, I decided that I would, you know, I would come 20 minutes early for my appointment and I would do two laps around the building before I would go in. So just like little things. And I noticed they started talking about their step counts, which we hadn't really been talking about, but they kind of got into not a competition with each other, but like kind of excited by 10 a.m. how many steps they'd already gotten. And so I think that like your encouragement also just, you know, simple movement, walking little things was really good. Yeah, and also just the idea of it being a group and people creating this support system amongst themselves. We would have people sometimes then become partners, walking partners and meeting each other at certain times, or just like you're saying, the strategies that they would suggest. One of my favorites was we had a woman in our group who regularly ate lunch at McDonald's and got two cheeseburgers. And she told us her strategy was she left one bite and then the next time she went, she left two bites, then three bites till she got down to just one hamburger. Oh my gosh, that's so cool. Yeah. And the thing is when she told that people got ideas, but they were also like could kind of cheer her on. Exactly, exactly. Yeah. Yeah. So one thing someone also wrote in and I, you know, this is not just relevant to this period we just went through with COVID, but I think just generally, have you ever tried to implement the program virtually? And if so, how did that go? Any tips for doing that? I haven't on my own, but we have had people write in and ask about doing that. And I think that the participant, a manual, I couldn't think of the word, makes that easier to do it so that the person does have something that they're following through. And you could do it either individually or as a group virtually following the manual. So I think taking advantage of the manual and making sure that the person has it available to them and then, you know, taking advantage of the manual and making sure that the person has it available to them and then going step-by-step. There actually could be some advantages. So for example, when you're doing food labels, you could ask the person to go in their own pantry and find foods. You can use strategies that are in the person's own home. Yeah, I like that. And we even had some people, they got into that idea of doing things during the commercials where they would use their canned food as their weights, right, like just things that they had in their own home. They wouldn't have to buy anything like that. Let's talk for a minute, because I really resonated with your interpretation of your first set of results about having a context for wellness, you know, in addition to just implementing the program. One of the things I remember that I think was actually a really cool thing that happened during one of the programs that I had been working on was that we got leadership at the clinic to agree to change out the vending machine contents. And, you know, I think, you know, everybody was like stunned. They came and they were like, wait, where are all the chips and the snowballs and all the things I usually get there? And it really shook things up. And you don't realize how many, like a lot of them get a snack out of there. And so if there are, and it gave them new ideas of what could be a reasonable snack. So I think as clinicians and as individuals, you know, helping our clients get to some of their recovery goals around weight and wellness, you know, look around our offices, you know, what kind of clues are we giving out around weight and wellness? Can you think of anything else other than our vending machines that are kind of places, maybe Coke machines too? Yeah, I think that, I also think just the messages and the way we talk, you know, we talk about broccoli or, and we, instead of getting excited about fruits and vegetables. And I do think that that's part of the, like making a culture, you know, just having a whole discussion about the different kinds of apples there are and, you know, and trying them and getting excited about how great they taste or I like this one and you like that one, instead of seeing it as a deprivation, really the way that we use our words and frame the things that we're doing. I love that idea of like an apple tasting. That's such a cool idea to have something like that, where you could have a bunch of different apples and have, you know, an apple tasting at four o'clock one day and that would be really cool. All right, let me look, I've been asking all my own questions. Let me look back at what our audience says. So one person wanted to know, in your studies when you've done, you've randomized to intervention or control and, you know, you compared those two, they were wondering what typically was the control group? So the control group continued to receive whatever services were available at their setting. Okay, so some people might have been at a setting where there was some good stuff. Yeah, some were and some weren't. Yeah. Okay. But it was actually their settings where there was good stuff, where we tended to benefit more from the good stuff. Okay, okay. Well, you were kind of, I think that's what you were saying about the context of a kind of a wellness program. Gotcha. Well, one of your big fans wrote in, this person said, your manuals and efforts have always been something I've looked forward to, back to your grocery shopping days. I guess there must've been a program early on and you're, so this person's been following you for a while. For programs in New England, do you know whether there might be OT students who could connect to for internships or implement in clubhouses? What do you think about connecting with OT programs? Do they often have students who are interested in programs like this wellness program? Yeah, in fact, the exercise videos were created by OT students. Really? Okay. And so I had a group of students that helped me lead the first time we ever did New R. And so it's really a perfect opportunity for students to learn how to lead a group and to have this very specific manual that gives them instructions for how to go about doing that. So I think that if you have students available to you, you could investigate your local community programs and see if they'd be willing to implement this. I find that a lot of community programs are really excited about doing this topic. Right. I mean, it was kind of interesting. I remember once going to dietary at the hospital that I worked with and said, are there any dieticians who'd like to come over and run this program with us? And they were like, that's really not our scope. We're really worried about the foods on the wards and things like this. And also there was kind of a, sadly, a little bit of a stigma about working with people with serious mental illness. They were kind of like, we don't really know how to work with those individuals. And we ended up saying, okay, we hear you. What about pairing one of you with one of us? And that really worked out well. So I think if we think broadly about who is in the hospital, the outpatient setting, there are probably a lot of different departments who maybe not solely would do this on their own, but would be willing to pair with us and would be a nice compliment, you know, to thinking about wellness and diet and exercise. Yeah, I strongly agree with you. Both with Renew and NewR, I worked with a dietician and she initially, she was faculty academician with a lot of research background, but had never worked with people with serious mental illness. So it was her first experience. So she was bringing the information on diet and weight loss that she was really an expert in. And I was bringing, working with people that had serious mental illness and it really complimented each other. And then we included peer support people as leaders in the intervention. Oh, I'm really glad you mentioned that here at the end, because I do think that peer support specialists can be such, can either be leaders or compliments to these kinds of programs and can be models in so many ways and can help, you know, really bring the class alive. So I really love that idea. What a pleasure it was to talk with you today. Really loved kind of brainstorming with you about these wellness programs and about how to implement them and think about tailoring them for different locations. So thank you so much. I'm gonna move on. So if there are any topics covered in today's webinar that you would like to discuss with your colleagues in the mental health field, post a question or comment in our SMI advisors webinar round table topics discussion area. This is an easy way to network and share ideas with other clinicians who participated in this webinar. Additionally, if you have any question about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of our SMI advisor national experts. This service is available to all mental health clinicians, peer support specialists, administrators, anyone else in the mental health field who works with individuals who have SMI. It's completely free confidential service. We'd love to hear from you. Now, SMI advisor offers more evidence-based guidance on recovery interventions, such as this fact sheet, 10 tips to use a recovery perspective in your practice. This fact sheet provides valuable tips and recommendations on how to use recovery perspective to transform how you connect with individuals who have SMI. Access this resource by clicking the link in the chat or by downloading the slides. Just wanted to highlight an extra resource today that might be of interest. So to claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Now, I'd love for you to join us in two weeks on April 20th as Dr. Judith Cook and Tanya Lang present Peer Delivery of Evidence-Based Supported Employment, Expanding the Vocational Workforce. It's gonna be another excellent webinar. And we know a lot of our clients want to get back to work. So let's regroup again on April 20th. I'd love to see you all. This free webinar again is on April 20th at 3 p.m. That's a Thursday. Thank you so much for joining us today. Until next time, everyone, take care. Bye-bye.

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