The lived experience of exercise in persons with depression: A journey to finding a sense of contentment

ABSTRACT

Background

Depression is often part of the embodied experience of persons living with pain and other health conditions. In addition to other benefits, exercise has been recognized to reduce depressive symptoms. Physiotherapists help persons to develop multidimensional understanding including an understanding of how exercise can help manage symptoms, and how they can individualize exercise to them. Thus, physiotherapists need insights into how exercise is experienced and meaningfully related to depression.

Purpose

This study aimed to explore the lived experience of exercise in persons with depression.

Methods

In this interpretive (hermeneutic) phenomenological study, participants with depression were purposively recruited and data collected via semi-structured interviews. Hermeneutic analysis was used alongside the crafting of hermeneutic stories to reveal the meaning of exercise for these participants.

Findings

Participants conveyed their experience of exercise as a journey to finding a sense of contentment. Two master themes: 1) Finding the exercise for me; and 2) the experienced importance of the environment, illuminated participants’ journey to finding a sense of contentment through exercise. Two subthemes 1) changing sense of self; and 2) building resilience further described participants’ experience.

Conclusion

Physiotherapists may reflect on these individual exercise stories and share these insights with persons receiving their care to explore if exercise may help them to find a sense of contentment.

KEYWORDS:

• Exercise
• physical activity
• depression
• phenomenology
• experience

Introduction

Depression is reported to be one of the most prevalent and debilitating forms of psychopathology (LeMoult and Gotlib, 2019), suffered by an estimated 11% of adults in the UK (McManus, Bebbington, Jenkins, and Brugha, 2016). The global burden of disease study reported a 50% increase in depression between 1990 and 2017 (Liu et al., 2020). This is set to rise further, with those experiencing depression and anxiety having doubled during the global COVID-19 pandemic (Kwong et al., 2021). The National Institute for Health and Care Excellence (NICE) guidelines advocate the use of pharmacological treatment alongside psychological intervention in the treatment of moderate to severe depression (Ekkekakis, Hartman, and Ladwig, 2018). Exercise has been recognized as an alternative or adjunct treatment for reducing depressive symptoms (Danielsson, Noras, Waern, and Carlsson, 2013) with meta-analyses demonstrating that exercise has a large and significant effect on depression for clinically diagnosed adult patients (Kvam, Kleppe, and Nordhus, 2016; Morres et al., 2019; Schuch et al., 2016).

Quantitative research investigating the relationship between exercise and depression has highlighted aspects of the exercise experience that affect mood outcomes. For instance, a meta-analysis reported larger effects for supervised, moderate, aerobic exercise (Schuch et al., 2016). Conversely, a randomized controlled trial (RCT) in women living with depression found greater improvements in depression following exercise at a preferred rather than a prescribed intensity (Callaghan, Khalil, Morres, and Carter, 2011). This highlights the importance of individuals’ subjective experiences of exercise and the need for physiotherapists and others who prescribe exercise to better understand the experience from the perspective of those experiencing it, including gaining insights into how it is meaningfully related to depression. Qualitative research seeking rich insights into the experience of exercise among persons with depression has explored the experience of a specific interventions; for example an exercise counseling session for women with postnatal depression (Pritchett et al., 2020) and personal training in a gym setting (Serrander, Bremander, Jarbin, and Larsson, 2021) and a physiotherapist guided exercise program for persons experiencing major depression (Danielsson, Kihlbom, and Rosberg, 2016). Although the experiences of these structured exercise programs varied, participants’ experiences included feelings of joy and vitality (Serrander, Bremander, Jarbin, and Larsson, 2021) and feeling more alive (Danielsson, Kihlbom, and Rosberg, 2016). However, engaging in and maintaining self-directed exercise is challenging, particularly for persons living with depression (Kamimura et al., 2014) and there is a paucity of evidence exploring the lived experience of self-directed exercise in persons with depression in order to capture the varied meaning of exercise participation during depressive episodes.

In recent years, physiotherapy has undergone a paradigm shift from a biomedical to a biopsychosocial model of care (Daluiso-King and Hebron, 2022). When practicing with a biopsychosocial framework of practice, physiotherapists help persons to consider and better understand multidimensional aspects of their complaint and facilitate them in developing self-management strategies. This includes greater attention to health promotion (Royal Society for Public Health, 2015) and a recognition of the importance of Making Every Contact Count by incorporating healthy conversations (National Institute for Health and Care Excellence, 2014) including those pertaining to mental health. A contemporary, holistic perspective acknowledges the inseparability of physical and mental health as illustrated by the poorer quality of life and increased risk of developing cardiovascular disease in persons suffering from depression (Luo et al., 2018). Exercises and movement form the roots of physiotherapy practice and remain central in physiotherapy practice and a recent systematic review and meta-analysis highlighted the importance of physiotherapists in design and implementation of exercise interventions for persons with depression (Davis and McGrane, 2021). However, physiotherapists could benefit from a deeper understanding of how exercise is meaningfully related to mental health in order to develop more embodied rational understanding (Todres, 2008). These insights may help physiotherapist and other health professionals to explore with persons suffering from depression, if and how exercise may be useful for them. Therefore, this study aimed to explore the lived experience of self-directed exercise in persons with depression.

Methodology

This interpretive (hermeneutic) phenomenological study explored the meaning of lived through experiences of exercise during periods of depression. Drawing on Heidegger’s hermeneutic phenomenology, the authors took a perspective that the realities of individuals are constructed by “being-in” the world in which they live (Dahlberg, Dahlberg, and Nystrom, 2008; Lopez and Willis, 2004; Neubauer, Witkop, and Varpio, 2019) and thus this study aimed to illuminate the variation in the experience of exercise while suffering from depression.

Participants

Four participants who had experience of exercising through periods of depression, were purposely recruited to this study via twitter. Recruitment of a small number of participants is common in phenomenological research as it enables the researcher to obtain rich (thick) descriptions and allows prolonged engagement with the data (Finlay, 2011; Smith, Flowers, and Larkin, 2009). Participants were eligible for the study if they were over the age of 18 and identified themselves as having exercised during episodes of depression. Those with suicidal attempts, severe depression, individuals outside of the UK and non-English speakers were excluded from this study. The first four volunteers who met the inclusion criteria and were available for interview were recruited (Table 1). Participants received an information sheet and signed a consent form. This study received ethical approval by the University of Brighton research ethics and governance committee.

Table 1. Details of participants (names are pseudonyms)

Tom	38-year-old with moderate depression. Takes anti-depressant medication. Full-time employment in maintenance.
Jacob	63-year-old with moderate depression. Takes anti-depressant medication. Full time NHS worker.
Paige	23-year-old with moderate depression. No Anti-depressant medication. Full time employment in retail
Natasha	45-year-old with moderate depression. No medication. Full time counsellor

Throughout the study, the researchers adopted the phenomenological attitude by attempting to hold back their everyday understandings and look for the phenomenon of interest as it revealed itself. Individual interviews were conducted via Skype with the second author who is a MSc Physiotherapy student with a first degree in Sports Therapy. They lasted a mean of 52 minutes. The interviews began by explaining “There are no right or wrong answers, I just want to understand your experiences as you experience them, to understand what it is like for you to exercise when you are experiencing depression.” The researcher sought to explore the phenomenon on its own terms, rather than according to pre-defined categories. Concrete examples of lived through experiences of exercising with depression were sought and thus the opening question was: “Would you be happy to tell me about a time when you exercised during a period of depression? … .Please take your time to think back to that time … .Could you describe it to me in as much detail as possible?” The researcher aimed to gain thick descriptions by using exploratory prompts such as: “You mentioned x, can you help me understand that?” “What did you do at that time, how did you do it?” Participants were allowed to speak freely and openly about their experience, but if they deviated from discussing the phenomenon of exercise during a period of depression, then the researcher guided them, by asking them if they would be happy to share another example of exercise. The interviews were audio recorded and transcribed verbatim. Participants were assigned pseudonyms to maintain their anonymity.

Data analysis

Hermeneutic analysis was performed on individual transcripts before looking across the collective whole. Initially the transcripts were read and re-read by both researchers to familiarize them with each participants’ account and gain a sense of the whole data. The researchers took time to dwell in the data, looking for what was implied and uncover hidden meanings, as well as exploring what was explicitly given (Dahlberg, Dahlberg, and Nystrom, 2008; Finlay, 2011). Next, the transcripts were divided into meaning units (i.e. parts of the text containing a meaning). The second author repeatedly engaged with the transcripts, making comments related to each of the meaning units that were descriptive, linguistic, conceptual and embodied and the development of themes arose from these. Following this, the grouping of themes from each transcript took place. In an operationalization of the hermeneutic circle, the researchers moved back and forth between the meaning units and the whole transcript, staying open to finding new interpretations throughout. Next, in an idiographic approach which focuses of the subjective experiences of individuals, hermeneutic stories were crafted from each participant’s accounts. The aim of the stories was to evocatively capture each participant’s ways of being, thinking and acting in the world and illuminate what is known but often forgotten or overlooked (Crowther, Ironside, Spence, and Smythe, 2017). The hermeneutic stories were crafted by removing repetition and detail that did not add to the story. Then linking words were added and the order of sentences was changed to allow the stories to flow. Throughout, care was taken to maintain the sentences which contained the meaning (Crowther, Ironside, Spence, and Smythe, 2017).

The themes from all four individual transcripts were brought together to generate master themes. To highlight the varied ways in which participants experienced the phenomenon, this stage required attention to the differences and similarities that emerged. In a continued operationalization of the hermeneutic circle, the second author continued to move back and forth between the parts of one transcript and the whole, and between the transcripts and the hermeneutic stories. The first author a physiotherapist and academic, experienced in qualitative research, reviewed each stage of the analysis and at each point, entered reflexive, dialogic discussion related to the interpretations with the second author. The main themes were drawn upon to develop an understanding of the deeper meaning, and to form a picture containing the individual’s perspectives and experiences.

Findings

In this study, participants living with depression described exercise as a vehicle through which they took a journey to finding a sense of contentment. Two interconnected master themes: 1) Finding the exercise for me; and 2) The experienced importance of the environment illuminate participants’ journey to finding a sense of contentment through exercise. Two subthemes were uncovered: 1) changing sense of self; and 2) building resilience further reveal participants’ experience.

Finding the exercise for me

All participants conveyed the experienced significance of finding the exercise for them. Participants described using trial and error in order to find the exercise that was meaningful for them in relation to their depression. This is elucidated by Natasha’s descriptions of finding yoga after having tried other forms of exercise and by Tom who tried going to the gym after finding a sense of contentment through running.

“ … . yoga to me was the biggest form of exercise that really helped me …… When I took that first step, I felt so positive because I connected with it so well and it didn’t take any energy from me. Having depression, I had no energy, but completing the yoga I felt so energized instead of feeling so worn out and tired.” (Natasha)

“so, I went to the gym with my brother, and I was very self-conscious and very nervous, and it didn’t work for me.” “ … . so, I stopped that and carried on running and I was fine” (Tom)

Tom’s description also illuminates the interconnectedness between the themes finding the exercise for me and the experienced importance of the environment as in the gym environment Tom experienced anxiety. Tom’s experience of exercising in the gym environment is partially mirrored by Paige who despite experiencing the gym as a place where she could set and achieve goals described the environment and culture as a “double edge sword.”

“It probably took me a good 6/7 months to kind of do my thing, I call it the ‘big boy area’ because, you get these big men, swinging around these heavy weights and showing their manliness, and it’s very intimidating.” (Paige)

The variation within Paige’s account echoed the more positively or negatively related experience of the environment evident between the participants. Jacob’s described his positive experiences of exercising in a natural environment by illuminating the haptic and auditory sense of the elements. His evocative description of exercising in nature being ‘magical’ further emphasizes the meaningfulness of the environment while exercising.

“I go out for a brisk walk and let the wind blow through, and it blows all the problems away from you, I find it really magical …… it makes me feel free, free from this hell around you and I just have a brisk walk and listen to the waves on the beach.” …… … “Walking in the woods and swimming in the sea, It’s a type of wildness, and freedom. Its wildness that you can’t control, it’s nature and it’s rare and its freedom. I’m free from my own head; I’m free from the dark fogginess.” (Jacob)

The interconnected themes of finding the exercise for me and the experienced importance of environment were described by participants as creating a context that enabled and were intertwined with a changing sense of self.

Changing sense of self

The sub theme a changing sense of self conveys the participants’ changing perception of themselves and the world around them. This is illuminated by Natasha, for whom exercise brought a change in perspective and understandings as she reconnected with herself and others.

“You have to grow out of the depression, because everything you are is in it and you have to do something different to change … I agree, without the yoga and that I wouldn’t be as I am today. I wouldn’t see the world or everyone in it the same.” (Natasha)

This journey through depression to a change in sense of self resonates with Jacob, who highlighted the shift in his perception of being in control and an interconnected sense of increased confidence and autonomy.

“I think it let me feel more in control of what was happening mentally, it gave me a sense of that I could now look after myself and actually do this, I couldn’t always change what had happened but it allowed me to change the way I felt myself. It felt, empowering, I was doing something and not letting something bad happen to me.” (Jacob)

The changing sense of self was further characterized by “distraction,” “clearing my mind,” “freedom,” “escape” and “peace and happiness.” These characteristics were present in all participants’ descriptions. Exercise was conveyed as a “distraction” from invading thoughts by creating an external focus of attention toward their body and the environment which led to a sense of “clearing my mind.”

“It’s more a way of a distraction, as you need to do a really good work out, you do need to be really focused, and put it in a box and lock it away and deal with it later …… .I start to think clearer; it’s a time of chill and peace for me, the fogginess disperses.” (Paige)

“my mind is blank, my mind is just gradually clearing, not numb but just blank. I am just noticing my feet on the surface of the floor and the noises that are surrounding me.” (Jacob)

“Some people may like do a yoga thing or something, but the running, I felt it cleared my head of things, even moving forward to the next day or week and stuff.” (Tom)

Participants viewed exercise as a means of “escape” from the grasp of depression toward finding a sense of “freedom.” The experienced importance of the environment was meaningfully connected to this changing sense of self as explained by Jacob.

“It’s almost like my freedom, it’s free and allows me to express my happiness. There is no one telling me what to do, there is no one judging it or me. For example, a tree, the way it grows, how it stands, no one can change that. Like the sea, you can’t tame it, it is pure freedom, and walking and swimming transfers me that freedom.” (Jacob)

Multiple repetition of the word “freedom” in both Jacob and Tom’s concrete descriptions of exercise highlight its importance in helping them to manage their symptoms.

“It gives me freedom, it gives me that freedom and takes me out of my normal day to day worries, even for anyone, that’s my go too to help me and although everyone has different things that helps but it gives me freedom. … . I felt good afterwards, not elated but I did feel different and I felt good. It went on from there for a few days, then I noticed a little bit of improvement physically and mentally, and then it went on from there. Being able to feel that it’s doing something for you, gave me a sense of hope, this was my escape.” (Tom)

Finding the exercise for me was conveyed as a means of finding “peace and happiness” and again was intertwined with the experienced importance of the environment. However, Jacob implied that this sense of peace is contained to times when he is exercising.

“I just find inner peace for a short period of time during the day, I feel happy at last. I try to stay out early in the morning and just walk around where I am and feel free.” (Jacob)

In contrast, Tom’s experience gives a different take on finding peace and happiness, highlighting variation in a changing sense of self. Tom’s description of exercise providing him with a second chance of living displays how powerful exercise was in changing his sense of self.

“So, running really gave me something, it gave me my life back. I really feel that finding exercise was my second chance at living life, as it should be lived … . happy, at peace in your own mind and have something that makes you truly happy.” (Tom)

Building resilience

Finding the exercise for me was meaningfully connected to participants building resilience through perseverance and determination, which appeared to help them gain confidence.

“with the running it was very self-motivating, you can stop at any time and turn around and go back and you will be fine. You managed to push through that point … . I just knew that if I ran, it would go. It was a simple Pavlov’s dog theory, I learnt that if I felt this way and then I done this I would feel better. It seemed quite logical to me, I felt different after it, so I felt like I had a new energy.” (Natasha)

Building resilience was further characterized by, learning to reflect, achievement, and pride. Tom’s reflections led him to recognize his achievements and “feel proud.” This is something that Tom referred to as carrying on in “day to day life” as he could “reflect back on” these feeling to “use as a tool” when faced with difficult scenarios.

“If I could run around an unknown place, in the daytime, wearing like all jogging gear, with headphones on, sweating, right and I think, and I’m worried about people looking at me. If I can do it looking like that, I can do it, dressed normally, not sweating, and just looking normal you know … .I feel proud of myself then, so that becomes another thing, so I was like, yeah that’s good, I could do that again. I can do that … . You feel like you’ve achieved a goal, you feel like you have done something.” (Tom)

Paige further highlighted determination and achieving goals as important factors in building a sense of pride, which helped her manage depression.

“It’s meaningful in a sense that I haven’t let the depression stop me from achieving something, it is an achievement, it may not be a massive academic achievement, but it is personal for me, so hitting a personal best shows that I can work towards something despite being depressed I guess.” (Paige)

Hermeneutic stories

Each participant’s account was crafted into a hermeneutic story to illuminate how each of the themes were interconnected within their accounts.

Tom - in the mind zone

Tom’s story conveys the meaning of being outside in the dark away from others as opposed to the gym environment, and the importance of running as the exercise for him, providing a sense of freedom. Through running, he met goals, leading to a sense of achievement and pride, building his resilience and helping him to find peace. A change in his sense of self and sense of contentment were illuminated by increased confidence and feeling good about himself and “living life as it should be happy and at peace”.

Vignette 1: Tom’s story - in the mind zone

My exercise journey started after a GP told me to try exercising which prompted me to speak with my brother whom is a keen runner. He usually runs around five kilometres, and so I made this my target. I waited until it was dark outside. I had more confidence about going out at night as there were fewer people around to see me. I started road running, and the first time I didn’t really achieve a great distance as I got out of breath and tired. However, when I got back home, I felt as if I had achieved a goal. It gave me the feeling of being able to achieve something. I carried on with the road running, and eventually reached the five-kilometre goal. By this point I had built up a lot of confidence, I could feel it slowly building. I began to notice this confidence during the day at work, I felt as if I was conversing with people more regularly. I acknowledged an improvement in myself, so I created another goal. I then began to go out during the daytime, running around the park. I found the key was to set goals which would lead to a sense of achievement and pride when completed. Doing so boosted my confidence and I began to feel good about myself. The exercise led to a change in my lifestyle, I changed my diet and also began to drink less alcohol, and I even carried on with goal setting in day-to-day life.

 Following the boost in my confidence, I decided to join my brother at the gym. I was very self-conscious and nervous being there around lots of people in this unfamiliar environment and so it didn’t work for me. I just knew it wasn’t my thing, and I felt I wasn’t able to set myself any goals. For me it is running. I feel it clears my head of things, even moving into the next day or week. The running has become my go to. A means of escape. I put my music on, and begin to run, focusing on just these two things and nothing else. I forget about my negative thoughts and take no notice of the people or place. I’m in a little zone, focused just on the running and music and nothing can pull me away from it, the running is like a mind zone drug for me. I now run in completely unknown environments, and I have no negative thoughts whilst doing so as I’m in the zone. I’m discovering, building confidence and knocking depression and anxiety on the head.

 After I got into the running, I injured my knee and had to stop running for a while. I thought that everything would come back or that I would return to my old self, but I didn’t. I couldn’t run for around a month or so, and as soon as my knee recovered, I returned to running and I actually looked forward to it. It’s not so much the running now as a means of a quick fix but the memories of it that help me. If I have a bad day or feel a sense of depression, I think about little things and remember that I was fine then, so I will be fine now. I now use it as a tool. All in all, the running provided me with freedom and even time out from life. Running really did give me something, it gave me my life back, living life as it should be lived, happy and at peace in my own mind.

Natasha - Transferable energy

Natasha’s story conveys the meaning of finding a new energy through Yoga movements, providing a means of motivation and determination. Yoga enabled her to improve her confidence and build resilience, which collectively gave her a sense of escape and a sense of contentment.

Vignette 2: Natasha’s story -Transferable energy

During my depressive episodes, I was trapped by my thoughts, and I felt as if I was in survival mode; on a type of autopilot the whole time. At times when I have had depressive episodes and bad things are going on, exercising has always brought me back from it. To me, yoga was the exercise that really helped. I remember the first time I went. I had been experiencing anxiety and depression for at least four months and was on medication. The yoga class was hard, but by the end of it I felt a complete sense of calm. I felt like I had returned to my own body and I was back inside my head. Over the course of one session I felt a lightness which was a dramatic difference for me, and I was hooked. Yoga gave me a feeling of positivity; it felt like a step in the right direction. This first step I took created such a positive feeling as I connected with it so well. It didn’t take any energy from me, but actually gave me energy.

 I tried running and was able to use it as a tool to move energy along. It gave me a sense of self-motivation and determination. I knew that when I had a horrible feeling in my body, it needed to go somewhere. It was then a simple Pavlov’s dog theory; I knew that if I ran, it would disappear. This seemed quite logical to me, I felt different after running, I had a new energy. The feeling of being stuck or heavy would disperse and I would feel I had greater control mentally, it felt empowering. It was a means of escape and way of managing thoughts and feelings. Although running was particularly effective, I found that the best thing for me was yoga. Yoga was what first got me back into movement, and once I had that, the energy starts to flow again. I was able to bring myself to a calmer state and develop some coping and focusing strategies through yoga. I am now more confident and balanced; I know how to take care of myself now. Exercise has led to a more positive mind-set, and without yoga I wouldn’t be where I am today. I wouldn’t see the world or those within it the same as I do now. Exercise directed me to a positive place in which I am able to work through the depression rather than battle it.

Paige - The double-edged sword

Paige’s story conveys the experienced importance of the environment where one exercises. The story captures the gym as place where she is able to achieve and a place of distraction from depressive thoughts, which bring her peace, and a sense of contentment. However, the story captures how the environment can decrease her confidence and how the gym culture can create an intimidating environment.

Vignette 3: Paige’s story - The double-edged sword

I go to the gym around five times a week, and my goal is to build muscle and tone up. I don’t know if I have ever used exercise as a coping mechanism, but it does make you feel good. The good feeling can last for a really long time. However, it can be a double-edged sword: On one hand, going to the gym and reaching goals, makes you feel good about yourself and takes you away from the negative thoughts; on the other hand, it can be very negative, as social media presents you with these unachievable body shapes and unachievable goals. With social media and the gyms, being around these ‘gym shark girls’ with flat stomachs and big bottoms, when you work so hard and don’t achieve that, it makes you feel worse. My self-esteem and self-image are affected as I think I may not be as desirable as ‘her’ and I constantly compare myself to others which makes the depression worse.

 I decided to get a personal trainer for expert advice. We would go into the weights section. My personal trainer said that my confidence is the main thing to work on, as my form was good. Being told this brought a good feeling, that really boosted by confidence. Following my sessions with the personal trainer, it took me around six to seven months to go into this area to do my own exercise program. I call the weights section the ‘big boy area’ as you get all of these big men swinging their heavy weights around and showing their manliness, and it’s very intimidating. I began to hit personal bests, and this was an achievement. It shows that I can work towards something despite being depressed, and so it’s meaningful in the sense that I haven’t let the depression stop me from achieving something.

 The gym really is a way of distraction; I am able to shut everything out and forget about it all, which gives me the sense of freedom after locking it away in a box. I think more clearly during exercise, and I find it a time of peace as the fogginess disperses. I think it can be such a good distraction as everything I am thinking about is forgotten, due to shifting the focus onto the session. When I am having bad thoughts, it can be so very draining, so being preoccupied with exercise takes my attention away and it’s peaceful as my mind is taken away to something completely different. Even after the exercise, the thoughts are dampened, they are still there and they come back, however they are not as bad.

Jacob - The wind blows all of my problems away

Jacob’s story conveys the experienced importance of exercise in natural environments away from others as a place where he finds peace, happiness, and freedom for short periods. Exercising in these natural environments was described as particularly important in reaching a clear mind and is meaningfully associated with building of resilience and a sense of contentment.

Vignette 4: Jacob’s story - The wind blows my problems away

My head generally feels very cloudy, very foggy, like a storm. I do whatever physical activity I can really, just by doing gardening, simple things, like going for a walk. Anything to distract myself from what I am thinking in my head. Out of everything, I most frequently go for long walks in the woods or along the beach and swim in the sea or local swimming pool. Walking in the woods or swimming in the sea, gives an overall sense of wildness that you can’t control, it’s nature, it’s untamed and it’s freedom. I find that these places are where I’m free from my own head, and so I’m free from the dark fogginess and hell around me. I let the wind blow through me, and it blows all the problems away, I find it really magical. I find inner peace for a short period of time, I feel happy at last, relaxed and calm. I feel as if I can just walk off and keep walking, it gets me away from everyone and away from the dark place. It recharges my batteries and I know the option is always there for me to access my freedom.

 When I swim, its complete freedom and you escape your own mind. Last week I didn’t want to go, but as soon as I hit the water my mind was clear, and I didn’t have bad thoughts. I had been swimming for 2 hours and didn’t realise. I don’t think of anything during the moment of exercise, my brain completely shuts off and my focus turns to the exercise. But the effects of exercise do differ. Sometimes I feel revitalised during and after exercise, and sometimes, once the exercise is finished, the power comes back on. A type of neon light strip comes back and ruins the freedom and blind me, and then I know I am back in reality again. Although I recognise that there are these two completely different aspects to it, what I do know is, exercise has given me the courage I need; it has enabled me to go outside and do things that I enjoy.

Discussion

Participants in this study described a journey toward finding a sense of contentment through exercise participation. They portrayed finding the exercise for them as pivotal in being able to manage their depressive symptoms. This was described as a trial and error process, which was elucidated by concrete examples of them trying new forms of exercise, but then returning to the exercise for them. Once found, they expressed a sense of connection to this form of exercise. Finding a sense of contentment through exercise was meaningfully related to participants’ changing sense of self and their identities as exercising persons. This changing sense of self was illuminated by participants’ descriptions of them gaining a sense of control that was interconnected with distraction from depressive thoughts, feeling of escape and an overall sense of peace and happiness. This resonates with studies reporting on the positive effects of exercise identify formation, for example the discovery of exercise and sport in men with serious mental illness helped them to rebuilt or maintain a positive sense of self and identity (Carless and Douglas, 2008) and in a study of older women, discovering and constructing exercise identity was associated with feelings of achievement, control, a sense of belonging, and increased social interaction (Hardcastle and Taylor, 2005).

The concept of exercise identity is where one has a self-concept of oneself as an exercising or physically active person. It takes time to ‘shape’ one’s exercise identity and, identity development and formation is a complex process that can change over time and is related to interactions with others, the context and embodiment (Rossing, Ronglan, and Scott, 2016). This reflects the experiences of participants in this study who provided concrete example of the significance of interaction with others in their exercise identity construction. For example, Tom who fearing others judgment initially chose to exercise in the dark, but as his exercise identity strengthened became open to exercising in more visible spaces. Tom’s account also illuminates the sense of space and how it is temporally lived through. The lived meaning of geographic space was also evident in other participants’ accounts which highlighted the meaning of environment.

The experienced importance of the environment was dominant within the participants’ accounts of finding the exercise for them. Tom, Jacob and Natasha all described exercising outdoors; for Jacob the importance of the natural environment dominated his story. Participants expressed a sense of a transferable freedom and happiness from the “untamed” nature surrounding them during exercise. This resonates with the concept of ‘green’ exercise. Exercise or physical activity in nature may be a way of distracting attention, directing it toward pleasant stimuli (Yeh et al., 2016) and improving psychological health and wellbeing (Berman et al., 2012; Lawton, Brymer, Clough, and Denovan, 2017; Mitchell, 2013). With exercising in natural environments resulting in greater improvement in mood and lower risk of mental health issues compared to exercising in urban environments (Berman et al., 2012; Mitchell, 2013).

In contrast to the natural environment, the participants’ accounts of exercising in the gym environment and gym culture were less positive. Physical activity has long been reported as a mechanism promoting positive self-esteem, body image and self-efficacy (Kamimura et al., 2014). However, in the current study participants’ accounts of exercise within a gym setting were illuminated by descriptions of self-consciousness, uncertainty in their body image and lowered self-esteem. One participant described the gym setting as a “double edged sword” with lowered self-esteem being related to a constant comparison of one’s appearance to others, and in contrast, an environment for reaching goals, including those related to appearance. This echoes the findings from Prichard and Tiggemann (2008) whom identified that motivations for exercise within a fitness center environment were more highly related to body image and appearance and may lead to negative effects on mental health and poorer body image. One’s self esteem and wellbeing are affected by both our own and others (real or perceived) reactions to our bodies (Williams and Bendelow, 1996). This may particularly resonate in this study due to its western society context, which has a dominant health and fitness culture. In this culture, there is power in the body’s physical and social capital and arguably, it is the appearance of the body, rather than its ability to function that is valued (Bourdieu, 1991; Rossing, Ronglan, and Scott, 2016).

Participants conveyed exercise as a self-management tool, as although they identified exercise as a means of finding a sense of contentment, depressive episodes still occurred. These participants developed an understanding of their use of exercises in developing pride, confidence and self-esteem, which helped them to build resilience. This resilience was meaningfully related to finding a sense of contentment as development of contentment is not simply because one feels better, and has increased life satisfaction, but is due to development of resources to encourage the promotion of living well and self-satisfaction (Cohn et al., 2009). This resonates with self-determination theory a theory of human motivation which recognizes the intrinsic motivation from a gaining a sense of autonomy and satisfaction (Ryan and Deci, 2000).

The population of persons suffering with mental health problems has been steadily increasing and the reverberations from COVID-19 are likely to set to increase this further. Grief, loss, biographical disruption and long-COVID are likely to impact persons’ mental health well into the future. Exercise, rehabilitation and health promotion are core skills in physiotherapy practice and a more embodied holistic approach to physiotherapy culture and practice is growing (Nicholls and Holmes, 2012). With this evolving culture, physiotherapists need to understand the experiences of exercise from the perspectives of persons receiving their care, particularly those from more marginalized groups and those who may have less established exercise identities. Understanding the struggle individuals may face when trying to become more physically active within society may help physiotherapists engender a coaching approach and open healthy conversations which include prompting or aiding persons receiving their care to experiment with different forms of exercise and exercise spaces. We hope that these conversations will help persons living with depression navigate a journey to finding their exercise identity and that they will be able to use exercise to help them manage their symptoms and find a sense of contentment.

Methodological considerations and limitations

The experience which this research explored is one in which the second author has experience, and it is acknowledged that this may be reflected within the interpretive processes. Hermeneutic phenomenology recognizes the researchers past experiences and knowledge as valuable guides that lead them to the experiences or phenomenon that are worthy of exploration (Neubauer, Witkop, and Varpio, 2019). Throughout all phases of analysis, there was reflexive dialogic discussion between the first and second author to enhance the study’s trustworthiness. A cyclical hermeneutic process was used which involved moving between parts of each interview (i.e. the meaning units) to the whole. Then moving back and forth across cases searching for varied and significant meanings. This study did not use participant validation, as in agreement with prominent phenomenological researchers we do not believe that it is compatible with hermeneutic phenomenology (Crowther, Ironside, Spence, and Smythe, 2017; Finlay, 2011; Giorgi, 2005). Interpretive hermeneutic phenomenology requires researchers to adopt the phenomenological attitude and follows an iterative analysis process within and between transcripts; a process that we cannot expect participants to do. Nor do we claim data saturation, as in line with phenomenological philosophy, we believe that new interpretations are always possible. These participants may have self-selected for this study because of their more positively related experiences of exercise and thus this research may not reflect the experience of other who have not found exercise to be meaningful for them. We do not claim transferability of findings, these are the experiences of these participants at this point in time; we hope that readers will dwell in these participants’ stories and take time to consider how they may hold meaning within their context and for persons receiving their care.

Conclusion

This interpretive phenomenological study aimed to explore how exercise was meaningful to persons with depression. Participants described a journey to finding a sense of contentment through exercise. This was described as a trial and error process to finding a form of exercise and exercise environment through which they developed an exercise identity, changing sense of self and building of resilience. Physiotherapists and health professionals may reflect on these persons individual exercise stories and share these insights with persons receiving their care to explore if exercise may help them to find a sense of contentment.

Acknowledgments

The authors would like to thank participants for their time and for sharing their stories.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.