For individuals experiencing mental health problems and the challenges caused by using drugs or alcohol, the public health system as well as volunteer organizations offer a diversity of treatments and rehabilitation activities. Evidence-based strategies for improvement of such mental health problems include cognitive therapy (Fischer, Baucom, & Cohen, 2016; Roberts, Roberts, Jones, & Bisson, 2016) and physical activity (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005; Durstine et al., 2000; Glasper, 2016; Stubbs et al., 2018; Trivedi, Greer, Grannemann, Chambliss, & Jordan, 2006). Developing appropriate and supportive therapy for individuals lacking initiative or empowerment calls for creativity because psychosocial challenges and health inequalities must be considered (Stansfield & Bell, 2019). Mental health nurses emphasize health promotion and recovery (Biong, Karlsson, & Svensson, 2008), and encourage performance of activities of daily living for those in need of help, supervision, and support.
When the goals are to improve the will to live, enhance quality of life, and support self-care, the use of the biopsychosocial model (Engel, 2012) often is recommended due to its holistic approach that incorporates biological, mental, and social perspectives. In addition, aspects of prevention and rehabilitation, such as those outlined in the Ottawa Charter for Health Promotion (1986), might serve as a guide for organizations seeking to introduce helpful interventions. User participation is essential for meeting personal aims and individual challenges. Dekker and Williams (2017) highlighted a user-centered participatory design for developing serious games as interventions for anxiety and depression. In an integrative review, Jørgensen and Rendtorff (2018) emphasized the importance of specific knowledge about patient participation in mental health care activities. Developing activities that seem attractive and enjoyable from the users' perspective may improve motivation for involvement. However, to investigate this assumption, users' perspectives and their immediate aims first must be identified.
The current article describes an exploratory study with a user-centered participatory design that assessed the use of serious games for anxiety and depression in participants involved in one particular activity: playing golf. In Europe, the Scots have a long tradition of playing golf (access https://www.standrews.com). The essence of golf is to hit a little ball with a club and reach a hole in the ground with a minimum of hits. Golf simulators are common and used particularly during the winter season for practicing and perfecting one's game. Enjoyed by millions of people all over the world, golf is a game that requires physical and mental awareness. Golf also is a game that players can enjoy while competing and socializing with others. As recommended by Stansfield and Bell (2019), this activity links socialization to a physical activity. Golf is a game that can be played by all, men and women, old and young.
Playing golf is a cognitive and physical challenge due to the skill involved in hitting the ball from the correct angle with the right touch to carry the ball optimally toward the next hole (Evans & Tuttle, 2015). Clark, Tofler, and Lardon (2005) have outlined the mental routines required, particularly for competitive golfers, because each golf swing lasts only 3 seconds, and the total duration of the swings for a whole course round is just 3 to 4 minutes. Except when using a simulator, golfers spend a long time walking on the course, sometimes as long as 4 hours to complete an 18-hole game. Golf, therefore, encourages social contact among the players when walking around in groups through the course. The topic for conversation in this setting often is improvement of one's personal golf performance. Therefore, playing golf is mentally, socially, and physically stimulating and challenging.
Research is limited regarding the impact of playing golf on the health and daily activities of individuals who have mental health problems and use drugs or alcohol. Carless and Douglas (2004) studied nine men with mental health issues who participated in a golf program in the United Kingdom. These men described encouraging and threatening factors in joining the program. Key factors included “making a safety net,” “bubbling about golf,” and “a relaxing sport.” In addition, Carless and Douglas (2004) mentioned challenges as “negative competition” and “time to move on.” Flores (2014) described rehabilitation benefits of a golf clinic for U.S. military personnel and Veterans with disabilities. However, no significant changes for participants related to self-efficacy, fatigue, pain, anxiety, and depression resulted from the program. Because only 13 individuals completed the program, it is possible the negative result may be attributed to lack of statistical power because of the small sample size (type II error).
In a scoping review of 301 articles, Murray et al. (2017) emphasized the relationship between golf and health. The authors concluded that golf, a moderately intense physical activity, is associated with physical health. Playing golf might improve cardiovascular, respiratory, and metabolic processes, and thereby improve feelings of fitness. However, the authors claimed there was limited evidence related to golf and mental health, and they recommended studying golf and mental health, health behavior change, and economic effects in specific populations. According to that review and a search of the literature, there is scarce research about the therapeutic effects of playing golf on mental health in particular groups. This invites further studies, and because research-based knowledge is limited, studies with different designs are warranted.
The aim of the current qualitative study was to explore the experiences of individuals with mental health problems or previous substance use after a systematic introduction to golf activities. The study examined the perceived impact on participants' physical and mental health, social contact, and daily activities, as well as an overall evaluation of involvement in a “Golf as Therapy” (GaT) group.
In existence for more than one decade, GaT is a program offered by a private legacy of senior golfers (i.e., individuals dedicated to the golf sport). The legacy applied for and received grants from private sponsors independent of official health and social services. The GaT program stays in contact with both golf clubs and institutions treating clients with mental health problems or substance use. GaT administrators help institutions select proper candidates with mental disorders or previous substance use for recruitment to the GaT program. The local clubs offer participants golf trainers, golf simulators, and free access to the golf course and supply participants with necessary golf equipment. Participants form groups of five to eight participants who meet at the golf course weekly for 3 to 4 hours of golfing and social networking. The program is free of charge for participants. For those living in an institution, the administration organizes transportation to the golf course. However, most GaT participants live by themselves and manage their own transport.
At the time of inclusion to this study, none of the participants held a job; however, they were enrolled in individual and group interventions. One of the authors (E.K.G.) conducted individual face-to-face interviews with 12 participants (informants) (nine men and three women) from among 157 participants enrolled in the GaT program. The GaT administrator, who knew the names of those joining the GaT groups, recruited the study participants. The recruitment process included providing information about the study to GaT participants; a total of 10 to 12 participants, preferably both men and women, was needed for the study. To avoid possible coercion, the recruiter informed potential informants that neither participation nor non-participation would have consequences for further membership in the GaT program. The informants provided written informed consent with contact information prior to the interviewer receiving their documents.
The interviews were conducted at the golf courses or at suitable offices close to where participants lived. Five informants (three men and two women) were from rural golf courses, and seven informants (six men and one woman) were from urban courses, although not located in the inner city. Interviews lasted from 26 to 55 minutes, yielding 202 pages of transcribed text.
After de-identification of the interview transcripts, the authors individually read the transcripts and determined their meaning units before collaborating to interpret the manifest and latent concepts and identify subcategories, categories, and themes (Graneheim, Lindgren, & Lundman, 2017). Graneheim and Lundman (2004) recommend this approach as a means of achieving credibility and trustworthiness. They suggest presenting the findings in a diagram in which the content could be understood in two directions (i.e., from meaning units to themes and vice versa).
One of the GaT informants read all of the interviews and provided valuable input to the first steps in the analytic process. He determined meaning units relevant from his perspective, and he later confirmed the content of the table presenting examples of the analytic process. This participant was central in the process of selecting the quotations describing the essential findings, and he also provided feedback on the first draft of this article.
The quotations as well as the transparent presentation of the meaning units, subcategories, and categories serve as background for readers to develop familiarity with the data and confidence in the authors' interpretation of the material.
The study was approved by the Norwegian Centre for Research Data (NSD). The NSD decided the GaT administrator should make the initial contact with possible participants. All participants delivered written consents. The raw data from this study are stored by the NSD.
Participants' ages ranged from 30 to 58, and they attended the GaT groups due to mental health problems or previous substance use. Participants gave rich descriptions of their experiences in their GaT groups, particularly regarding the impact on their health and daily activities. The overall impression was the GaT experiences had shaped a new direction in life by ameliorating physical fitness, generating a social meeting place, increasing focus and concentration, giving practical help and support, and reducing their mental symptom burden.
To achieve these particular improvements (presented as categories), subcategories such as forgetting problems, weight loss, better sleep, a good feeling of tiredness, skilled trainers, and disconnection were articulated. The meaning units, subcategories, and categories thereby emerged from the data as manifest findings (Table 1). For latent findings (i.e., what was interpreted as the underlying message from the participants in this study), the theme of shaping of a new direction in life was highlighted by all informants. During the interviews, the first author (E.K.G.) had the impression that informants were deeply moved when talking about their attachment with their GaT group and trainers, and about changes in their habits and their ability to improve their daily activities.
Overview of the Analysis with Meaning Units, Subcategories, Categories, and Theme
Ameliorated Physical Fitness
The new direction in terms of physical improvement, which was categorized as ameliorated physical fitness, left increased physical activity and weight loss as fundamental experiences. GaT consisted of physical activities such as walking and hitting the golf ball, demanding bodily fitness and precise movements, as well as coordination and evaluation of direction and distance. One of the informants described his initial physical experience as “…when trying the first golf swings, the instructor shouted, ‘Oh my God, you are sweating.’ So I was in pretty bad shape.”
Several participants proudly described weight reduction and the impact of physical fitness and improved physical function. One participant said, “I lost 21 kg [46 lb]. When entering golf, I also entered other activities.” The influence of improved physical fitness had positive consequences such as motivation for other kinds of activities and focus. One participant noted that “…when experiencing problems I gained weight enormously, but the GaT has inspired me to exercise, and I have lost tremendous number of kilos [lbs].” Another participant noted that “…when outdoors walking I feel a rinsing [cleansing] process, unwinding. And I can focus on the next swing.” One participant said, “Outdoor activities = golf. I am not fond of hiking in the forest by my own.”
The exercise involved in swinging the golf club gave participants an awareness of their muscles and their strength. One participant commented, “In the beginning I felt muscular pain and complained about my bad shoulders and sore muscles in my back. Now I have rhythm in my body.” Another informant had a different perspective about the best activity, noting that even the simulator required physical endurance: “I prefer playing the simulator. It is relaxing and causes me no pressure, so I can perform better.”
Generated a Social Meeting Place
This category characterized the new direction of creating a location with others facing the same challenges in life. The subcategories included relatedness, exert social skills, and arena for activity. One of the participants summarized all of the latter aspects:
When someone has a “bad day,” others from the group take contact for a chat and some positive comments to try get them started. I feel receiving support and attention when I need it. It is relatedness and safety in itself.
Another participant said, “I feel belonging to this place.” Four informants specifically emphasized the social value; comments included: “It provides so much fun and they include me,” and “I prefer to play with others–I find it boring being alone.” Another participant described a different perspective on connection: “As long as I find it interesting, I am not concerned about others. I prefer playing alone–it is comfortable and I do not need to engage in conversation.” Connection in this case involved joining the social meeting place, which for this person was an interesting arena for physical activity and nothing more than that.
Increased Focus and Concentration
Increased focus and concentration represent the mental awareness required in playing golf. As part of this mental awareness, forgetting problems and disconnect seem to describe this new direction. One woman stated, “During the game I am extremely concentrated. After the Golf-as-Therapy I am tired as I have used my dose of energy.” Another participant emphasized the importance of focus while playing: “I lose concentration when people talk and when kidding. On the other hand, this is a part of the total picture which is positive.” Another participant emphasized the necessity of assessing the distances, which demands focus: “It is hard to assess the distance and the power you need to reach the goal.”
Disconnect or “staying off-line” might be interpreted as figurative presence during the game, but at the same time feeling socially protected and locked out from the society. One participant noted, “I am not physically tired after playing golf; however, my head is tired.” Another participant said, “Previously, I checked my mobile phone. Now I leave the cell phone in my car. I do not need it at the course.”
Practical Help and Support
Shaping a new direction in life for these informants seemed to be dependent on practical help and support. Several pointed out that they had expectations and were open for new impressions; however, they were dependent on helpful and skilled leaders. One participant said, “They were surprisingly encouraging and helpful, and I had reached a state in which I was not that inhibited by anxiety.” Another participant noted, “[It was] extremely hard in the beginning, the body would not obey…I emphasize the availability of skillful trainers.” Another participant said, “I have always got a feeling of doing things in a wrong way. In this group, we may play incorrectly, but no one says ‘shame on you.’”
From the participants' point of view, leadership with an attitude to boost and encourage was experienced as emphatic and supportive. One participant noted, “He [the instructor] managed to see me; he sensed my condition and accommodated the performance level to my limitations.” Another participant said, “I am sure the group would not have managed without leaders. They are always supportive, even when you repeatedly fail. In order for me to succeed, the correction had to be motivating, not strict.” One participant noted, “The trainer is extremely clever and human. He shows us, spends time with each of us, and is always kind and gentle.”
The interviews showed participants experienced the mastering of practical tasks, which gave them a sense of feeling good after a practical performance, particularly the golf play, as well as other daily activities. One participant said, “The importance is the feeling of mastery, which makes the body function and gives me optimism in my daily life. Since I want to be independent of others the aim is to get my driving license again.” Another participant noted, “After a kind of adrenalin-kick [playing golf], I get inner calmness to make my day.”
Reduced Mental Symptom Burden
The informants in this study considered reduced mental symptom burden to be a meaningful description of their experiences. With a good feeling of tiredness, better sleep, and relaxation, they could shape a new direction in life. One informant said, “After completing the round, my head is totally empty. Coming home, lying on my sofa, I think, ‘Gosh, now I am comfortably tired, both mentally and physically.’” Another participant said, “I am so tired and satisfied after the Golf-as-Therapy that I fall out of the car when turning back home.”
Quality of sleep was improved due to exercise. One participant said, “When you are run down; then you can sleep.” Another participant noted, “After walking the course and performance playing, I am tired. The result is better sleep than before.” Problems such as symptoms or lack of energy had to be relieved to perform better in daily life, as exemplified by the ability to start the day. One participant said:
I look forward to rise in the morning–it has not always been like that! I have joined the Golf-as-Therapy group even when having a flu because I want to be with them. I have reflected on this, and in the future I want to have a job for which I want to get up early in the morning.
During the interviews, many informants emphasized the ability to keep calm during the game. Some of them mentioned the relaxation required for a new direction in life. One participant commented, “Previously, when shopping, payment was a challenge, and I said, ‘Keep the change’ because I trembled tremendously. Now it is gone!” Another participant said, “It has been a roller coaster; however, when I felt a part of this, I got rid of boredom and stupid thoughts.” Other comments included, “We have a lot of gallows humor; I laugh while tears are dripping,” and “…the activity is more therapeutic when having fun and feeling free.”
In summary, the theme Shaping a New Direction in Life indicates that the condition experienced by participants had changed. Either as a single activity or in conjunction with other activities along with appropriate support and follow-up, GaT served as a catalyst for a new direction in life.
The aim of the current study was to explore the experiences of individuals who joined a GaT group, including the possible impact on participants' physical and mental health as well as the influence on their social contact and daily activities. The findings revealed a positive influence on health and social well-being in addition to positive changes in daily activities.
Previous studies on golf as activity have emphasized attendance in a golf program in which only men participated (Carless & Douglas, 2004). Therefore, comparison to the current sample is difficult. However, the categories described by Carless and Douglas (2004), such as “making a safety net,” “bubbling about golf,” and “a relaxing sport,” correspond to some of the findings from the current study in the category, for example, “generated a social meeting place,” where participants were able to chat and exchange words.
Flores (2014) highlighted one particular target group (military personnel and Veterans) that is a different group of informants and participants than in the current study. Flores (2014) found no significant changes in self-efficacy and health aspects for the 13 participants in the study, but different methodological approaches and measures do not allow for meaningful comparisons with the current study. Murray et al. (2017) referred to several studies describing the overall positive effect of golf on lipid profile and improved body composition.
Adams, Goldufsky, and Schlaff (2016) emphasized gender differences when designing educational programs on nutrition, weight, and lifestyle changes for athletes. Their study highlights the importance of balanced diet to avoid eating disorders and to maintain a healthy lifestyle. The findings from the current study captured the theme To Shape a New Direction in Life, which may correspond to aspects of the concept lifestyle changes. Weight and gender differences seemed irrelevant for the GaT group. Both quantitative and qualitative studies have described mental benefits related to personal and group identity, as well as to social connectedness (Murray et al., 2017). These findings correspond to the current study, although described in different terms (e.g., relatedness, social meeting place, and belonging).
Several theories describe and explain changes in life. Self-determination theory (SDT) (Ryan & Deci, 2000) particularly emphasizes intrinsic motives and needs to change lifestyle. A background including autonomy, competence, and relatedness is a key factor for activities, performance persistence, and creativity requiring motivation and engagement. In the current study, excitement to participate in GaT is linked to what might be interpreted as autonomy. Focus and concentration, in addition to managed performance, could be interpreted as competence, whereas social meeting place and connectedness could serve as relatedness. The subcategories and categories from the current study therefore might correspond to the fundamental components of SDT.
However, in the current study, external factors such as a beautiful golf course, skillful trainers, and helpful leaders also played a significant role. The exclusive GaT provision gave participants the opportunity to join golf courses and obtain free professional instruction as well as access to available services. From the findings of the current study, it was not possible to identify all of the valuable factors for shaping a new direction in participants' lives. Nevertheless, it is interesting that participants emphasized internal and external motivation during the interviews, which according to SDT are factors crucial for change.
Although the initiators of GaT did not have any theoretical concept concerning their activity, for the informants in the current study, GaT provided a new direction in which the content seemed to fit the components for lifestyle changes. As several of the informants in this study indicated, GaT came at an appropriate time in their lives. This is an important factor because the GaT experience served as a catalyst for changes. User-centered participation is valuable for serious games used as therapy (Dekker & Williams, 2017). In the current study, the user-friendliness may be reflected upon regarding internal and external motivation (Ryan & Deci, 2000). User involvement was also considered in the way the GaT activity was offered. Motivation depends on individual engagement, which corresponds to user-involvement. The informants in the current study emphasized being taken seriously and receiving support. Thus, user-involvement may be interpreted as fundamental to shaping a new direction in life.
Qualitative approaches emphasize variations in perspectives from participants' experiences, which was the case in the current study. One of the informants preferred acting alone, did not appreciate conversation, preferred using the simulator rather than playing in the open air, and promoted improvement through precise hits. Other informants described obtaining satisfaction from walking and talking on the beautiful golf course. The one individual represents focused performance and perfectionism, whereas most of the other participants in this study seemed to appreciate the GaT activity by itself, along with social relatedness and support from the leaders and trainers.
Because the benefit of GaT includes physical fitness, social connection (although to a different degree), and reduced mental health symptoms, these aspects correspond to the ideal of the biopsychosocial model (Engel, 2012), which includes all of these characteristics. In addition, the aspects of prevention and rehabilitation described in the Ottawa Charter for Health Promotion (1986) also might correspond to the findings of the current study. GaT may be interpreted as a preventive activity as well as a part of rehabilitation and recovery for the participants of this study. The theme Shaping a New Direction in Life might be developed further to the metaphor “from hibernation to awakening,” capturing the new physical, social, and mental orientation due to GaT.
When the purpose is to improve physical fitness, mental health, and the ability to perform activities of daily living, different approaches are available. Structured activities like golf include several aspects, such as walking the course or using the golf simulator. The golf simulator is a digital device in addition to a place for physical performance. Lau, Smit, Fleming, and Riper (2017) examined serious games for mental health purposes and found promising results for symptom relief. Dekker and Williams (2017) identified 20 serious games with user-involvement that can prevent or treat anxiety and depression, or complement existing therapies. These games were all computer- or web-based. Although Dekker and Williams (2017) referred to serious games as educative rather than entertaining, the enjoyable aspect might influence involvement and participation in the game. Making the game or activity enjoyable is believed to reduce dropout rate (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Playing golf on a course in addition to using the simulator might be a good combination to ensure variation and sustain activity.
Beneficial treatment alliance is essential for mental health treatment (Biong et al., 2008). The findings of the current study indicate the treatment alliance with trainers, leaders, and the GaT group might provide external motivation for individuals to join the activity. The combination of internal and external motivation is necessary to shape a new direction, with knowledge giving clinical implications for designing activities for this target group. However, further studies are recommended to investigate the degree to which internal factors are of higher importance than external ones for individuals experiencing mental health problems and challenges with drug or alcohol use while enrolled in a GaT group.
Strengths and Limitations
Qualitative research seeks different perspectives from participants. Data from the interviews were collected from both rural and urban areas in Norway, which offered the advantage of capturing a broad view of the GaT experience. Qualitative studies are not intended to provide global answers. The purpose of studies based on small samples does not aim to generalize but rather to gain in-depth knowledge and new hypotheses from participants. The current study used an exploratory design, and the findings from the interviews provided a rich description of the experiences related to participating in GaT. One limitation to this study was the recruitment process of participants, who were invited by the GaT administrator. It is possible that the participants might be those individuals with the best connections to the administrator and therefore might be the most compliant. However, the NSD recommended this recruitment procedure. Another limitation is the follow up and particular content of the GaT program, which makes this study nontransferable to other groups. Finally, knowledge on diagnoses and current treatment programs available for participants could shed light on a valuable combination of interventions to improve participants' situations.
The main findings of the current study about the experiences of GaT members indicate a valuable activity that shaped a new direction in life for participants. In particular, participants described improved physical fitness, social contact, increased focus and concentration, improved daily activities, and reduced mental symptom burden, as well as the importance of practical help and support.
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Overview of the Analysis with Meaning Units, Subcategories, Categories, and Theme
|Walking as a cleansing process; losing a tremendous amount of weight||Activity; weight loss||Ameliorated physical fitness||Shaping a new direction in life|
|A chat and some nice words; belonging to this place||Relatedness; exert social skills; arena for activity||Generated a social meeting place|
|During the game, extremely concentrated; leave the cell phone||Forgetting problems; disconnect (i.e., staying off-line)||Increased focus and concentration|
|Extremely clever trainer; sensed my condition; entering golf and other activities||Skilled trainers; helpful leaders; managing practical tasks||Practical help and support|
|Look forward to rising in the morning; rid of boredom and stupid thoughts; being tired after walking the course||Good feeling of tiredness; better sleep; relaxation||Reduced mental symptom burden|