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British Cycling Coach Anthony and group looking a the physical impact of stress

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Smiles and fun Bouldering and Mountain Biking 🤪🤓😍

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Allen at RideLines Innerleithen was an epic course leader. A very tough few days mentally and physically 💪🤓🤔 a lot learnt and even more to practice and consolidate 🤓🤘

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Something similar but maybe in your area. Paul and his team are great at what they do and we are very happy to be working with them 👍

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Its been quite a journey to get to this point but we are delighted to be able to now share the news that we have our new team member in post to start working with partners on the innovative 'Trail Therapy' project.

This new project will offer two programmes with two distinct client groups under the banner of "Trail Therapy". The project is being supported by NatureScot, Edinburgh Napier University and Trek Bikes and will support and consolidate the therapeutic techniques delivered by mental health professionals.

It is a kick-start project that will result in novel preventative and therapeutic approaches, taking full advantage of Scotland's natural environment, responding directly to the mental health crisis we are facing. As a project it will lay the foundations for a structured, rigorously evaluated, nature-based solution to support our health service going forward and we cannot wait to get the ball rolling.

Read Full Press Release

NEW MTB & MENTAL HEALTH 'TRAIL THERAPY' PROJECT - READY TO RIDE

We're announcing an exciting, kick start project where mountain biking and contact with nature will form the core of an innovative approach to help people suffering from a sustained or acute period of mental ill-health. Following an extensive selection process, Scottish Cycling through their Developing Mountain Biking in Scotland (DMBinS) project, have appointed a Trail Therapy Mountain Bike Leader to deliver the project.

Paul MacFarlane, a highly qualified mountain bike leader with a breadth of experience delivering sessions to adults and young people alike, will take up the post in mid-April. Paul, who is also a mental health first aider, will be working in partnership with the NHS and Green Health Partnerships in Dundee and South Lanarkshire, delivering mountain biking sessions to two distinct client groups.

The nature-based project will help support and consolidate the therapeutic techniques delivered by mental health professionals within formal and informal healthcare settings to accelerate recovery, under the banner of 'Trail Therapy'.

Paul said: 'I am very much looking forward to taking up the role this month and beginning the process to ensure that 'Trail Therapy' is delivered as a complimentary technique to help those that need it."

"Now more than ever we need to be championing mental health and ensure that interventions to tackle the increasing stresses placed on the NHS and its support services are there when managing mental health issues. Community-based health initiatives are increasingly seen as the way forward, with NHS systems reaching the limits of their health-giving powers."

"We need an ever-increasing variety of tools within our mental health toolbox to support not only the individuals affected but the systems that currently try to care for them. This project connects participants to the benefits of 'green exercise' through mountain biking and offers one more tool in our toolkit.'

NatureScot is the main funder of this project which follows on from a successful pilot delivered by DMBinS and partners in the Scottish Borders in 2018.

Bridget Finton from NatureScot said, "We are delighted to have Paul in post to take Trail Therapy forward. This novel project takes full advantage of Scotland's amazing natural environment as a setting for this preventative and therapeutic approach. It fully supports NatureScot's Our Natural Health Service initiative and responds directly to the mental health crisis we are currently facing. As a partnership project it will lay the foundations for a structured, rigorously evaluated, nature-based solution to support our health service going forward."

The project will also be supported by Trek Bikes. Jez Loftus from Trek said, "As a company we are delighted to be involved and support this project. We truly believe that bikes are a tool to vastly improve people's lives and as an industry we have a real responsibility to be advocates for programmes such as this that harness the power of the bike.

Worldwide, now more than ever, people are struggling with their mental health and we are proud to be part of such an innovative project that will grow and be able to help those that really need help."

For more information on the project please contact Christine Fox, DMBinS

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NEW MTB & MENTAL HEALTH 'TRAIL THERAPY' PROJECT - READY TO RIDE - Riders - News - Developing Mountain Biking in Scotland

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Its been quite a journey to get to this point but we are delighted to be able to now share the news that we have our new team member in post to start working with partners on the innovative 'Trail Therapy' project.

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The North Face RED Trail Grisdale Lake District

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The North Face RED Trail Grisdale Lake District

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This one was a bucket lister for me and was true adventure….no other pics as too busy riding it 😩😆👍💪❤️🤙

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Gisburn Forest Trail Centre 🤓🥰 well close by in this shot !

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Whinslatter RED Alpine Trail North Lakes 

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Whinslatter RED Alpine Trail North Lakes 

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It is an EPIC ride 🤘

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Strange what you’ll find out on a ride 🤓

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Strange what you’ll find out on a ride 🤓

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British Medical Council Research on Bouldering for Depression 🤙

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British Medical Council Research on Bouldering for Depression 🤙

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Research article

Open Access

Published:

BMC Psychiatry 20, Article number: 116 (2020) Cite this article

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Abstract

Background

Recent scientific studies have suggested that climbing/bouldering is effective in alleviating depression when the comparison group was a waitlist control group, even when physical activity and other therapeutic approaches were controlled for. In the present study, we aimed to investigate the effectiveness of a manualised psychotherapeutic bouldering intervention for depressed individuals, compared with an active control group performing physical exercise alone.

Methods

In a multicentre randomised controlled intervention trial, 133 outpatients with depression were assigned to either a bouldering psychotherapy (BPT) group or a home-based supervised exercise programme (EP). Severity of depression as the primary outcome was assessed at baseline and directly after a ten-week intervention period using the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcomes included anxiety, coping skills, self-esteem, body image, and interpersonal sensitivity. We applied t-tests to test for differences within the groups (t0 vs. t1) and between the BPT and the EP and a multiple regression analysis with the post-intervention MADRS score as the dependent variable. The robustness of estimates was investigated with a sensitivity analyses.

Results

Patients in the BPT group showed a significantly larger decrease in depression scores compared with the EP on the MADRS (drop of 8.4 vs. 3.0 points, p = .002, Cohen's d = 0.55). In the confounder-adjusted regression analyses, group allocation was found to be the only significant predictor of the post-intervention MADRS score ( β = − 5.60, p = .001) besides the baseline MADRS score. Further significant differences in change scores between the BPT and the EP were found for anxiety ( p = .046, d = 0.35), body image ( p = .018, d = 0.42), and global self-esteem ( p = .011, d  = 0.45).

Conclusions

The study provides evidence that the manualised BPT is not only effective in alleviating depressive symptoms but even goes beyond the effect of mere physical exercise. Based on these findings, the BPT should be considered as a complementary therapeutic approach.

Trial registration

Trial identification number: ISRCTN12457760: Study KuS (Klettern und Stimmung - Climbing and Mood) combined boulder and psychotherapy against depression, registered retrospectively on July 26th, 2017.

Peer Review reports

Background

Worldwide, only one out of six individuals suffering from depression receives minimally adequate treatment, a finding that reveals a significant therapeutic supply gap in the mental health care system [ 1]. Besides a lack of therapists and thus long waiting times for a therapy place, a missing belief in the effectiveness of classical psychotherapeutic interventions as well as stigma play a major role when it comes to actively seek help for the treatment of mental problems [ 2]. Hence, there is a need for novel and complementary treatment options that exceed traditional therapeutic interventions. As such an alternative approach, physical activity has been found to be effective for the treatment of depression. Previous research has found antidepressant effects for various modes of exercise, ranging from endurance and aerobic exercise such as walking, running, and cycling [ 3, 4, 5, 6] to resistance and strength training [ 7, 8]. There is further scientific evidence of an association between low-intensity mindfulness-based techniques such as Yoga [ 9, 10, 11], Thai Chi, and Qigong [ 12, 13, 14], and an improvement in depressive symptoms. With moderate to large effect sizes (Cohen's d between 0.62 and 0.82), the antidepressant effect of physical exercise has turned out to be comparable to psychotherapy and antidepressant psycho-pharmaceuticals [ 6, 8, 15, 16]. Consequently, both the NICE guidelines [ 17] and the German guidelines for the treatment of depression [ 18] have included the recommendation to implement physical activity as a complementary therapeutic method in the standard treatment of depression. Though the efficacy of physical activity is widely accepted, it remains largely unclear which mode and intensity of exercise is most promising in alleviating depressive symptoms. While some studies have demonstrated that resistance exercise is superior to aerobic exercise [ 15], others have indicated stronger long-term effects of aerobic endurance training compared with strength training [ 19]. Regarding the intensity of training, the effectiveness of low-intensity yoga-based stretching exercises was found to be comparable to vigorous intensity aerobic training in treating mild to moderate depression [ 20]. A special mode of exercise that has gained increased attention in clinical practice lately and has already been applied as part of the overall treatment plan in several clinics involves bouldering, which is defined as climbing to moderate heights without the use of ropes or harnesses [ 21, 22]. Recent research has shown positive effects of climbing/bouldering not only on various health problems [ 23, 24, 25, 26, 27, 28] but also on mental disorders such as anxiety disorders [ 29], ADHD [ 29, 30], and eating disorders [ 29]. Several studies have indicated improvements related to climbing/bouldering in a number of domains that are believed to play an important role in the emergence and maintenance of depression, such as cognitive abilities [ 21, 29], self-confidence, self-esteem, self-efficacy [ 29, 31], and social skills [ 21, 29]. In line with these findings, there were some first indications that climbing and bouldering are effective in reducing depressive symptoms [ 21, 29, 32, 33]. However, conclusions regarding bouldering as an effective treatment for depression must be drawn with caution because existing studies are often limited by methodological problems such as small sample sizes, the use of unstandardised psychometric measures, no randomisation, or even the absence of any control groups [ 34]. Our work group [ 35, 36] conducted a randomised waitlist-controlled pilot study to investigate the effectiveness of an eight-week bouldering psychotherapeutic intervention on depressive symptoms in individuals with depression. Participants in the intervention group showed a significantly greater reduction in depressive symptoms (from a moderate to a mild severity level, Cohen's d = 0.77) as well as improvements in a number of other mental health outcomes (i.e. anxiety and self-management) compared with the waitlist control group. We controlled for the confounding effect of general physical activity with the use of accelerometres. However, no direct comparison between the bouldering therapy and a proper sports/physical exercise programme (i.e. in the form of a fitness workout) was drawn. To follow up on this idea, the main aim of the current study called StudyKuS (Studie KuS - ' Klettern und S timmung'; 'Climbing and Mood') was to investigate the effectiveness of a manualised bouldering psychotherapy (BPT), compared with exercise alone, in a large nationwide sample of outpatients with depression. For this purpose, we used an active control group, involving a home-based exercise programme (EP), instead of a waitlist control group. The home-based exercise programme was designed to be an externally supervised opportunity to engage in exercise such as often offered by health insurance providers. We hypothesised that participation at BPT would lead to a significantly greater reduction in depressive symptoms than mere physical activation in the form of the EP. The effect of BPT on other measures of mental health (e.g. self-esteem, coping skills, anxiety) was examined with an exploratory approach.

Methods

Study design

The study design was already described in detail in our study protocol and the following descriptions are based on the explanations there [ 37]. The StudyKuS began in 2016 as a multicentre, randomised, controlled study. It was conducted in three different regions across Germany: a) Erlangen/Nuremberg/Fuerth (metropolitan region), b) Weyarn (rural region), and c) Berlin (capital region). Within one region, the three interventions offered in the study (BPT, CBT or EP) took place during the same time period and were conducted in consecutive waves, with four waves in the Erlangen/Nuremberg/Fuerth region as well as the Weyarn region and two waves in the Berlin region. Participants within one region and one wave were randomly allocated to one of three groups (BPT, CBT, or EP). Subsequent to the therapy period, participants, who were assigned to the EP were offered the opportunity to participate in an additional ten-week bouldering group, which followed the same treatment plan as the BPT group and took place directly after the therapy period (see Fig. 1). Data were collected via computer-assisted telephone interviews (CATIs) before start of the therapy (t0), at the end of the therapy (t1), and 3 months (t2), 6 months (t3), and 12 months (t4) after the therapy period (Follow-Up). For details of the data collection please see our study protocol [ 37]. Interviewers conducting the CATIs were blinded with respect to participants' allocations. Participation was voluntary, and participants were free to leave the study at any time. All procedures were approved by the Friedrich-Alexander Universität of Erlangen-Nürnberg Ethics Committee (Ref. 360_16 B).

Study Design. Notes. BPT: Bouldering psychotherapy; CBT: cognitive behavioural therapy; EP: exercise programme; Erlangen and Weyarn/Munich: four waves, Berlin: two waves; measurement occasions are shown by using the fourth wave as an example

Interventions

Bouldering psychotherapy (BPT)

Our newly developed bouldering psychotherapy is a combination of bouldering and psychotherapy. The programme consists of ten consecutive sessions of 2 hours. In the current study, it took place in groups of about ten participants in a bouldering gym once a week in the late afternoon. In each study centre, therapeutic teams consisted of two therapists, but the personnel composition varied across the different waves of therapy because the therapists sometimes had other commitments (a total of nine climbing therapists). For qualification of the therapists see the study protocol [ 37]. Each of the ten BPT sessions focussed on a specific psychological topic that was considered to be relevant in the development and maintenance of depression. Table 1 shows an overview of the specific subjects covered in the ten therapeutic sessions [see also 37]. Each session was based on the BPT manual and followed a standardised procedure (introduction, action phase, closure), comprising mindfulness exercises, psychoeducational elements, topic-related bouldering exercises under therapeutic supervision, exchange of individual experiences between participants and transfer to daily life, body-related relaxation exercises, and free bouldering. The purpose of the bouldering exercises was to evoke underlying emotions (e.g. anxiety), unveil patients' characteristic patterns (e.g. avoidance), and enable patients to engage in new experiences (e.g. exposition: bouldering blindfolded). For a detailed description of the treatment, see the study protocol [ 37].

Table 1 Overview of sessions of the BPT [37]

Exercise programme (EP)

The home-based Exercise Programme was supposed to address the same muscles as used in bouldering. It consisted of a 20-min physical training programme that was conducted by the participants on their own at home, using a training DVD and/or a training manual (with instructions and explanations for all of the exercises). Additionally, participants received training material (e.g. a multifunctional latex band and training rings to enhance finger and arm power) as well as psychoeducational material explaining the positive effect of physical exercise on mood. Participants were instructed to perform the exercises about three times a week for ten weeks (resulting in 60 min per week, comparable to the 'active time' in the BPT group). At regular intervals, they received reminders and motivational material to keep on exercising. Depending on their personal preferences, participants were contacted via e-mail, telephone, or postal mail. As opposed to other Internet-based offers of therapy (i.e. by health insurance companies), people without Internet access or an e-mail address were also able to participate at the EP group. In addition, participants were provided with an exercise diary that encouraged them to record their training sessions and subsequently rate their mood. After the intervention period, the total rate of exercise was assessed in a personal interview with an external rater via self-report.

Cognitive behavioural therapy (CBT)

The third intervention that was applied was based on a classical cognitive behavioural group therapy but will not be described in detail because it is not relevant to the hypotheses we tested in this article. For a detailed description of the treatment, see the study protocol [ 37] and other publications by the work group.

Recruitment and randomisation

Between January 2017 and March 2018, participants were recruited by the distribution of informational materials (e.g. flyers, posters) in relevant institutions (e.g. psychiatric hospitals, psychotherapists' offices, primary care physicians' offices, pharmacies, support groups). Additionally presentations were held at local events and press releases were issued and addressed to different local newspapers and radio stations prior to the start of each intervention wave. A homepage ( www.studieKuS.de) and a Facebook account were created and regularly updated. Informational sessions were held by the study personnel, in which all people interested in the study were informed about the conditions surrounding a participation in the study (e.g. randomisation). Those willing to participate were asked to fill out a short screening questionnaire and to declare their written informed consent. All individuals fulfilling the inclusion criteria were informed that they had been included in the study and subsequently randomised blockwise within one region and one wave to one of the three groups (BPT, CBT, EP). Randomisation was stratified by sex and severity of depression (PHQ-9 scores 8-14 mild, 15-19 moderate, 20-27 severe depression). Randomisation was performed by the Institute of Medical Informatics, Biometrics, and Epidemiology (IMBE) at the Friedrich-Alexander-Universität Erlangen-Nürnberg with a computer-based system and was based on participants' codes without the statistician's knowledge of assignment to the intervention arms.

Inclusion and exclusion criteria

Eligibility was determined through the screening questionnaire handed out at the information sessions or upon request. Only a few inclusion and exclusion criteria were applied, in order to increase the external validity of the study. Potential participants were personally interviewed by the study personnel if the fulfilment of the inclusion or exclusion criteria was unclear. Inclusion criteria were acute depressive symptoms, informed consent to participate in the study (especially approval for randomised allocation and data collection), and the ability to get to the therapy locations. The presence (or absence) of depression was operationalised by a PHQ-9 score of at least eight points, ensuring a high level of sensitivity for all depressive disorders [ 38]. Exclusion criteria were an age under 18 years, a Body Mass index (BMI) under 17.5 or over 40, contemporary participation in another psychotherapeutic group therapy, started psychiatric medication or psychotherapy within the last 8 weeks, planned inpatient stay during the intervention period, physical contraindication for bouldering (physical disorders or pregnancy), specific psychiatric disorders (psychosis within the last 5 years, a manic episode within the last 5 years, substance addiction with substance abuse within the last year, borderline personality disorder diagnosis with self-harming behaviour during the last year), and acute suicidality [see also 37]. All participants were obliged to sign an anti-suicide contract for the duration of the study. After randomisation, participants were informed about their allocation and provided with all the necessary information about group participation.

Instruments

Primary outcome measure

Montgomery-Åsberg Depression Rating Scale (MADRS) [ 39]. The MADRS is one of the most commonly used rating scales for assessing core symptoms of depression [ 40]. It consists of ten items, which are rated by a clinician in a semi-structured interview on a seven-point scale with higher scores indicating greater severity of depression (ten or below: remission, greater than 31: severe depression) [ 41]. In our study, the structured interview guide for the Montgomery-Åsberg Depression Rating Scale (SIGMA) [ 40] was used, which offers a selection of different questions for each item.

Secondary outcome measures

Subscale interpersonal sensitivity of the Symptom-Checklist (SCL-90) [ 42, 43]. The SCL-90 is a self-report inventory which measures among other variables the intensity of distress experienced during the past 7 days caused by interpersonal sensitivity. Ratings on the five-point Likert-type scale were summed, and standardised t-values were computed, with higher scores indicating an increasing severity of symptoms.

Generalised Anxiety Disorder 7 (GAD-7) [ 44, 45]. The GAD-7 is a brief self-report questionnaire, asking patients how often they have felt bothered during the last two weeks by each of the seven core symptoms of generalised anxiety disorder. Items can be rated on a four-point scale, with higher sum scores indicating higher anxiety (≥ 5 mild ≥10 moderate, and ≥ 15 severe anxiety).

Subscale vital body dynamics of the Body Image Questionnaire (Fragebogen zum Körperbild, FKB-20) [ 46]. The FKB-20 assesses body image disturbances and subjective aspects of body experience. The vital body dynamics subscale consists of ten items rated on a five-point scale with higher sum scores indicating a more positive body image.

Subscale c oping of the Questionnaire on Resources and Self-Management Skills (Fragebogen zur Erfassung von Ressourcen und Selbstmanagementfähigkeiten, FERUS) [ 47]. The FERUS assesses an individual's health-related resources and manageability, among others on the subscale coping [ 48]. Twelve items are rated on a five-point Likert scale. Ratings were summed with higher test scores indicating better resources and manageability skills.

Rosenberg Self-Esteem Scale (R-SES) [ 49]. The R-SES is a self-report instrument for evaluating global self-worth. It consists of ten items answered on a four-point scale with higher values indicating higher self-esteem.

As an additional measure for depression the 9-Item Patient Health Questionnaire (PHQ-9) [ 44, 50] was applied. The PHQ-9 is a short self-assessment tool which is often used for the screening of depression in primary care settings [ 51]. Its nine items cover the nine DSM-IV criteria and are rated on a four-point scale. The total sum score suggests varying levels of depression (0-4 minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, 20-27 severe depression) [ 38, 50].

For all of the psychometric measures, change scores were computed as the difference between t1 and t0.

Other outcome measures

Other variables that were assessed either through the screening questionnaires or via the CATIs included, among others, sociodemographic data (e.g. age, gender, and level of education), body mass index (BMI), current therapeutic treatment (antidepressant medication, additional psychotherapy), psychiatric comorbidities, medical history of depression, critical life events, physical limitations, and attitude towards physical activity (positive or negative). The interview guide regarding those variables is presented in Additional file 1.

For a comprehensive depiction of all the measures we assessed, see the study protocol [ 37].

Statistical analysis

To increase the power of the statistical procedures, all participants in each group (BPT and EP) were combined across the three study centres and two/four waves for the main analyses. Descriptive statistics (frequencies, means, and standard deviations) were computed to illustrate sample and baseline characteristics. To assess the quality of the randomisation, differences between the EP and BPT groups in the variables of interest were evaluated via two-sample t-tests, U-tests, chi-square ( χ2) tests, and univariate analyses of variance (ANOVAs). The underlying assumptions of parametric tests were checked before using the Kolmogorov-Smirnov and Levene's test. Baseline variables that were significantly different between the two groups were included as confounders in the multiple regression model. All data were checked for plausibility. A missing data evaluation was carried out, and missing values were imputed using the expectation maximisation (EM) algorithm. The primary data analysis strategy was 'per protocol' (PP). Participants who dropped out during the intervention period were subsequently interviewed and included in the 'intention to treat' (ITT) analyses. Dropout analyses were computed to check for differences between participants who dropped out and those who completed the study, using χ ² tests, U-tests and two-sample t-tests.

To check for pre-post changes within the groups in the main outcome criterion (i.e. depressive symptoms assessed with the MADRS), paired t-tests were computed to compare the changes between t0 and t1 in both the BPT and EP group. To compare the improvements between the two groups, t-tests for independent groups were computed to compare the change scores (t1-t0) between the BPT and EP group. In addition, a multiple regression analysis was calculated to predict the post-intervention (t1) MADRS score from group allocation (BPT vs. EP), controlling for demographic variables (age, sex), participants' BMI, attitude towards sports, other therapeutic treatments (antidepressant medication, additional psychotherapy), and severity of depression at baseline (MADRS t0 score).

As a sensitivity analysis, additional analyses with ITT data were computed and compared with the results of the PP analyses. Furthermore, an additional regression analysis controlling for the study centre was calculated to rule out potential centre effects. Collinearity statistics were examined in advance to ensure there were no issues with multicollinearity.

Secondary outcomes as well as depression measured by the PHQ-9 were tested in an exploratory fashion. To check for improvements within the groups, paired t-tests were computed to assess changes between t0 and t1 for the EP and BPT. After checking for homogeneity of variance, change scores were compared with t-tests for independent groups and U-tests (as sensitivity analyses) between the two groups. As a measure of effect size, Cohen's d was calculated.

To determine consistency among the raters, for 10 (4%) of the pre-intervention (t0) and 11 (5%) of the post-intervention (t1) CATIs, a second person also rated the interviewee's answers on the SIGMA and intraclass correlations (ICCs) were computed across all groups to assess interrater reliability. For all analyses, a Type 1 error rate (alpha) of less than 5% was considered to indicate statistical significance. Statistical analyses were performed with the aid of the IBM SPSS Statistics 21 software.

Results

Description of study participants

The intervention period ran from May 2017 to June 2018. Of 332 individuals who attended the screening, 99 of them did not meet the inclusion criteria (see Fig. 2 for the reasons for exclusion). A total of 233 participants were included in the study (ITT). 79 participants were randomly assigned to the BPT, 77 to the CBT, and 77 to the EP group. Figure 2 shows the flow of participants through the study. During the course of the therapies, 35 participants either dropped out of the study (for their reasons, see Fig. 2) or participated in fewer than five sessions (50%) in their allocated group. The per protocol sample consisted of 198 participants (BPT: n = 64, CBT: n = 65, EP: n = 69; PP). For the analyses that we computed to investigate our specific research question, only participants in the BPT and EP groups (PP: n = 133) were included. All subsequent descriptions pertain to this subsample. Analyses involving the CBT group will be part of further investigations.

Consort Flow Chart. Notes. BPT: Bouldering psychotherapy, CBT: cognitive behavioural therapy, EP: exercise programme

The sample characteristics and group differences between the BPT and EP groups are shown in Table 2.

Table 2 Sample Characteristics

Of the 133 participants remaining after the 10 weeks (PP), 69.2% were female and 31.8% were male. The mean age of participants was 42 years ( SD = 12.5), the average weight fell within the normal range (BMI: M = 24.3, SD = 3.9), and the majority (61.7%) had completed 12 years of schooling. Almost all of the participants (97.7%) reported a positive attitude towards sports. Across the groups, around half of the participants (46.6%) underwent additional outpatient psychotherapy and received antidepressant medication (48.9%) in addition to participating in the study. More than two thirds of the participants (72.9%) reported at least one depressive episode before the current one, and more than half (55.9%) reported at least ten depressive episodes in the past or claimed to be suffering from chronic depression (the current episode had been running for more than 2 years). The average depression score at the beginning of the study indicated a moderate level of depression (PHQ-9: M = 13.4, SD = 5.2; MADRS: M = 22.8, SD = 9.0). Other baseline measures are presented in Table 2. Overall, the groups were comparable with respect to the baseline scores of the psychometric measures and key characteristics, with the exception of additional psychotherapeutic treatment: Participants in the EP group received additional psychotherapy less often ( n = 24, 34.8%) than the BPT group ( n = 38, 59.4%). Over the 10 weeks, participants in the BPT group took part in eight BPT sessions ( M = 7.91, SD = 1.48), and participants in the EP group engaged in 2.2 sessions of the exercise programme per week (in total: M = 21.90, SD = 14.04). Participants who dropped out between t0 and t1 ( n = 23) did not differ from the remaining sample in age, sex, BMI, additional psychotherapeutic or antidepressant treatment received, or severity of depression (PHQ-9 and MADRS scores at t0). The interrater reliability for the main outcome, the SIGMA, was excellent ( ICC = .985, 95% CI from .963 to .994, p  < .001).

Main outcome

Univariate results

Both groups indicated significant improvements in depressive symptoms after the ten-week intervention period. In the BPT group, depression scores dropped by 8.4 points on the MADRS (t0 = 23.5 vs. t1 = 15.1; p = .003) over the course of the ten-week intervention period, whereas the EP group's scores dropped by only 3.0 points on the MADRS (t0: 22.2 vs. t1: 19.2; p < .001) during the same time period (BPT vs. EP: p = .002) (see Fig. 3). On average, participants in the BPT group improved by more than one severity grade, from moderate to mild depression (MADRS score ≤ 19), while the improvement of the EP group remained within the same severity grade (moderate depression). The effect size (intervention vs. active control group) was moderate (Cohen's d = 0.55) (see Table 3). The sensitivity analysis with ITT data showed comparable results between groups (BPT: 8.1 vs. EP: 3.0, p = .001, Cohen's d = 0.53). For a better interpretation of the results, we included descriptive results of the third intervention arm, the CBT group, in Fig. 3.

Change in Depression Scores between t0 and t1 on the MADRS. Notes. BPT: Bouldering psychotherapy, CBT: cognitive behavioural therapy, EP: exercise programme

Table 3 Group Differences between the BPT and the EP Group for Change Scores between t0 and t1

Regression analysis

Results of the confounder-adjusted regression analysis (see Table 4) revealed a significant effect of group allocation (BPT vs. EP) on the depression score after the intervention period (MADRS at t1) with BPT participants showing significantly lower depressive symptoms than participants in the EP ( β = − 5.60, p = .001). In addition, the baseline depression score (MADRS at t0) emerged as a significant predictor ( β = 0.55, p < .001). No significant effects were found for any of the other control variables. The sensitivity analysis with ITT data showed similar results (group allocation: β = − 5.12, p = .001; MADRS t0: β = 0.55, p < .001) and no significant study centre effects were revealed (Berlin vs. Erlangen: β = 0.613, p = .739; Weyarn vs. Erlangen: β = 2.483, p  = .185).

Table 4 Summary of the Multiple Regression Analysis for Variables Predicting Depression (MADRS) at t1

Secondary outcomes

During the ten-week intervention period, participants in the BPT group showed significant positive changes in anxiety, body image, active and passive coping, global self-esteem and interpersonal sensitivity (see Table 3). For the EP, significant differences between t0 and t1 were observed for the same variables with the exception of body image and coping. However, pre-post changes were significantly higher within the BPT group compared with the EP group for anxiety (GAD-7: p = .046, d = 0.35), body image (FKB-20: p = .018, d = 0.42), and global self-esteem (R-SES: p = .011, d = 0.45) (see Table 3).

Results of the additional measure on depression, the PHQ-9, support the findings of the MADRS: Scores dropped by 4.7 points (t0 = 13.5 vs. t1 = 8.9; p = .003) in the BPT group and only by 2.6 points in the EP group (t0: 13.2 vs. t1: 10.6; p < .001) during the same time period (BPT vs. EP: p  = .041).

Discussion

To our knowledge, this is the first randomised controlled intervention trial to compare the benefits of a therapeutic bouldering intervention to that of a home-based physical exercise programme in outpatients with depression. As we expected, depressive symptoms were effectively reduced in both the bouldering therapy group and the exercise group during the ten-week intervention period. These results are in accordance with previous studies on the antidepressant effects of physical exercise [ 8] and also parallel previous findings by our work group on the benefits of psychotherapeutic bouldering in treating depressive symptoms [ 35, 36]. What has not been shown before and therefore represents new insights into the relation between physical activity and depression is the finding that the effect of the BPT seems to go even further than the effect of only physical activity. Comparing the change scores in the two groups, the benefits of therapeutic climbing significantly exceeded those of the exercise programme. While the scores of the participants in the BPT group dropped by 8.4 points on the MADRS, thus constituting an average improvement from moderate to mild depression, the scores of the participants in the EP group dropped by only 3.0 points on the MADRS and thereby remained within the range of moderate depression. Simultaneously, in the confounder-adjusted regression analysis, group allocation (BPT vs. EP) emerged as the only relevant predictor of the post-intervention depression score measured with the MADRS. These findings underpin and augment the previous results of our work group's pilot trial [ 36], which suggested therapeutic effects of a bouldering psychotherapy intervention on depressive symptoms even when general activity was controlled for. With a moderate effect size (Cohen's d) of 0.55 for the MADRS, the effect of the BPT intervention applied in the current study was weaker than that of the BPT in the pilot study (Cohen's d = 0.77). However, one important factor contributing to the less pronounced effect size is that in the present study, an active control group in the form of an exercise programme was used instead of an untreated waitlist control group as applied in the pilot study. Participants in the EP knew that they could participate in an additional subsequent BPT after they completed the EP in 10 weeks. Hope has been shown to be inversely correlated with depressive symptoms [ 52], hence we assume that the antidepressant effect of the EP was further increased by the expectation of an improvement through participation in the subsequent BPT group. Therefore, the effect of the EP is likely to be overestimated in our study.

Still, the moderate effect is comparable to the antidepressant effect of other short-term group therapies [ 53] or physical exercise [ 6, 54, 55, 56, 57, 58, 59]. In an exploratory approach, additional favourable effects of the EP as well as BPT were found for additional secondary mental health outcomes apart from depression. While participants in both groups showed improvements in anxiety, global self-esteem and interpersonal sensitivity after the ten-week intervention period, those in the BPT group even improved in body image and active and passive coping. As already observed for the primary outcome, significantly higher pre-post changes in anxiety, body image, and global self-esteem were revealed for the BPT compared with the EP, which again indicates the superiority of therapeutic bouldering to physical exercise alone. In summary, physical activity has been reconfirmed to play an important part in alleviating depressive symptoms. However, it seems to represent only one of several therapeutic factors through which our bouldering psychotherapy exerts its antidepressant effect.

Strengths and limitations of the study

Strengths

The StudyKuS is the first controlled intervention trial to compare the effectiveness of a manualised bouldering psychotherapy (BPT) with an active control group (EP) in a large nationwide sample of individuals suffering from depression. The randomised controlled but still naturalistic design involved only a few inclusion and exclusion criteria to maximise external validity and thus to allow for the generalisability of the findings. By randomly allocating participants to either the BPT group or the EP group, relevant confounding factors were controlled for, and a high level of internal validity was achieved. Depressiveness as the primary outcome was assessed via the MADRS, a clinician-rated interview, and we were thereby able to avoid the potential biases that are often associated with self-report questionnaires. To obtain a maximum of standardisation, interviewers followed a structured interview guide, which offered a selection of different questions for each of the MADRS items. Due to the longitudinal design of the study with a long follow-up period of 1 year, potential long-term effects of BPT as well as the EP can be investigated in future studies.

Limitations

Despite randomisation, a significant between-group difference in additional outpatient psychotherapy emerged at baseline in the direction that participants in the EP less often received additional psychotherapy than those in the BPT group. In order to rule out any bias in the results in favour of the BPT intervention, additional psychotherapy at baseline was controlled for in the multiple regression analysis and was found to have no significant effect on the post-intervention depressiveness score. Participants in the EP group were instructed to engage in the exercises given in the EP at least three times a week, and the number of sessions completed was assessed via self-report after the intervention period. However, there was no external control of the duration of each session or whether the training units were completed at all. In future studies, a more reliable assessment of the total amount of time spent exercising would be beneficial. With regard to the setting, it should be borne in mind that the BPT was conducted as a group intervention, and therefore, psychoeducation was provided by a therapist, whereas the EP was carried out alone at home, and psychoeducation was thus provided by a brochure. As the feeling of belonging to a group, called group cohesiveness, constitutes a therapeutic impact factor in the treatment of mental disorders [ 60], it is difficult to rule out the effect of the group when comparing the two interventions. An additional effect in favour of the BPT might have resulted from higher expectations of the BPT intervention as participants had specifically applied for a study on "bouldering". A benefit of the EP, as already mentioned before, was that the participants knew that they would be able to participate in a bouldering group after they completed the EP.

Future research perspectives

Regarding future research on this topic, a direct comparison between BPT and a regular non-psychotherapeutic bouldering group as well as other modes of group exercise (i.e. running groups) could help to provide insight into the underlying mechanisms. To go a step further, it would be of great interest to compare the effectiveness of BPT with established and guideline-recommended approaches for the treatment of depression such as cognitive behavioural therapy. Also, in order to draw reliable conclusions about the long-term effects of BPT, follow-up data (up to 1 year after the intervention) must be evaluated. Both questions will be dealt with by our work group. Finally, further studies involving specific target groups (i.e. grouped by sex, specific ages, participants' sportiness) and different mental disorders (i.e. somatic symptom disorder, substance addiction) would be beneficial in order to allow a selective, more targeted implementation of BPT.

Conclusions

The results of the current study provide support for previous findings in suggesting positive effects of physical activity and particularly bouldering in depressed individuals. Moreover, it is evident that our bouldering psychotherapy is not only efficacious in reducing depressive symptoms but even goes beyond the benefits of mere physical exercise. There is good reason to believe that psychotherapeutic bouldering may be a viable alternative to classical mental health treatments, particularly when addressing patients whose needs are not covered by the current care system. Future research on the efficacy of our bouldering psychotherapy on relevant subgroups and other mental disorders would be beneficial in order to allow a more targeted implementation of BPT in clinical practice.

Availability of data and materials

All the results supporting our conclusions are contained in the manuscript. The datasets that were used and/or analysed in the current study are available from the corresponding author upon reasonable request after the publication of the results.

Abbreviations

BMI:

Body Mass Index

BPT:

Bouldering Psychotherapy

CATI:

Computer-Assisted Telephone Interview

CBT:

Cognitive Behavioural Therapy

EP:

Home-Based Exercise Programme

FERUS:

Questionnaire on Resources and Self-Management Skills

FKB-20:

Body Image Questionnaire

GAD-7:

Generalised Anxiety Disorder 7

IQR:

Interquartile Range

M:

Mean

MADRS:

Montgomery-Åsberg Depression Rating Scale

MDN:

Median

PHQ-9:

Patient Health Questionnaire 9 Items

R-SES:

Rosenberg Self-Esteem Scale

SCL-90:

Symptom-Checklist

SD:

Standard Deviation

StudyKuS:

Study 'Climbing and Mood'

References

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Acknowledgements

We would like to thank the Oh Do Kwan- Stiftung Karl Wiedmeier + Ludmilla Pankofer and the Verein Aufwärts in Miesbach for their financial support of the study. We acknowledge support from the Friedrich-Alexander-Universität Erlangen-Nürnberg within the funding programme Open Access Publishing. We would also like to thank our student assistants for their dedicated support with the telephone interviews. Also, we acknowledge support by our language editor, Dr. Jane Zagorski. Finally, we want to thank all of the participants for providing data.

Funding

This work was supported by the charitable Oh Do Kwan- foundation Karl Wiedmeier + Ludmilla Pankofer (funding nearly 100% of the project's costs), represented by Dr. Michael Bonefeld, Neuhauser Str. 3, 80331 Munich, Germany. Additional support was received from the Förderverein Kletterzentrum Aufwärts in Miesbach, who funded the entrance fees for the Bouldering Gym in Weyarn, represented by Andreas Huber, Sepp-Sontheim-Str. 14b, 83714 Miesbach, Germany.

The funding body played no role in the design of the study and collection, analysis, or interpretation of data or in writing the manuscript.

Author information

Affiliations

1. Centre for Health Services Research in Medicine, Department of Psychiatry and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany

Nina Karg, Lisa Dorscht & Katharina Luttenberger

2. Department of Psychiatry and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany

Johannes Kornhuber

Contributions

JK, KL, LD, and NK designed the study. LD and NK were responsible for the implementation of the study, KL supervised the study. LD developed the CBT manual. NK developed the BPT manual. NK was responsible for the development and implementation of the telephone interviews. LD, NK, and KL analysed the data and drafted the manuscript. JK drafted parts of the manuscript. All authors have read and approved the final version of the manuscript.

Corresponding author

Correspondence to Nina Karg.

Ethics declarations

Ethics approval and consent to participate

All procedures were approved by the Friedrich-Alexander Universität of Erlangen-Nürnberg Ethics Committee (Ref. 360_16 B). Participation was voluntary, and participants were free to leave the study at any time. Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Karg, N., Dorscht, L., Kornhuber, J. et al. Bouldering psychotherapy is more effective in the treatment of depression than physical exercise alone: results of a multicentre randomised controlled intervention study. BMC Psychiatry 20, 116 (2020). https://doi.org/10.1186/s12888-020-02518-y
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Keywords

Depression

Physical exercise

Bouldering

Psychotherapy

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Bouldering psychotherapy is more effective in the treatment of depression than physical exercise alone: results of a multicentre randomised controlled intervention study - BMC Psychiatry

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Background Recent scientific studies have suggested that climbing/bouldering is effective in alleviating depression when the comparison group was a waitlist control group, even when physical activity and other therapeutic approaches were controlled for. In the present study, we aimed to investigate the effectiveness of a manualised psychotherapeutic bouldering intervention for depressed individuals, compared with an active control group performing physical exercise alone.

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How being active impacts mood, thinking and interactions 🤓🤙

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Bouldering Active for Mood (Anxiety and Depression) Mindfulness

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Abstract

Mindfulness is a meditative practice that has received increasing attention within positive psychology as an effective tool to increase wellbeing and decrease anxiety. Previous research has demonstrated that rock-climbers have a higher endorsement of mindfulness and life satisfaction than the general population; yet to date, no research has empirically explored the relationship between mindfulness and rock-climbing. In the current study fifty-nine participants (\( \overline{\mathrm{x}} \) = 20.63, SD = 1.60) were asked to complete measures of mindfulness, wellbeing and anxiety before and after participating in an 'intervention'. The intervention consisted of a mindfulness activity followed by either indoor bouldering (a form of rock-climbing) versus a physical activity control. A mixed ANOVA revealed that participation in bouldering increased the measure of mindfulness significantly more than the control activity; however, no significant group differences were found for the measures of wellbeing and anxiety. A regression analysis then revealed that group condition accounted for 33% of the variance in post-intervention mindfulness levels when controlling for baseline levels of mindfulness. This is the first study to experimentally demonstrate that engagement with rock-climbing increases mindfulness in young adults. Theoretically, the results have implications for our understanding of "flow" and optimal human experience. Practically, the study highlights the potential to implement rock-climbing as a resilience-building activity and integrate the sport within therapeutic frameworks.

Background

Mindfulness: A Review in the Context of Wellbeing & Anxiety

Over the past decade, there has been increasing attention directed towards positive psychology and understanding methods of nurturing positive mental health (Rybak, 2013). Since the 1970s, a prominent research topic within positive psychology has been the meditative practice mindfulness (Williams & Kabat-Zinn, 2013). The majority of psychological and neuroscientific studies define mindfulness as "paying attention in a particular way: on purpose, in the present moment and non-judgementally" (Kabat-Zinn, 1994). This definition was put forward by John Kabat-Zinn, who has been a pivotal figure in translating Buddhist mental training techniques into the context of psychological interventions (Malinowski, 2013). Kabat-Zinn's definition eloquently encompasses the three principal components of mindfulness: intention, attention and attitude (Shapiro et al., 2006). Intention, defined as the aims and motivations which underlie a practice, is argued to significantly impact on the benefits drawn from mindfulness (Shapiro & Schwartz, 2000); while attention and attitude embody the actual practice. Attention refers to being fully aware of one's internal experience, whereas attitude is concerned with the quality of the attention, being accepting, kind and curious (Ivtzan, 2016). Evidence indicates that higher levels of mindfulness are associated with life satisfaction (Schutte & Malouff, 2011), and higher degrees of the non-judgemental aspect of mindfulness are predictive of lower levels of stress and anxiety symptomology (Cash & Whittingham, 2010). Furthermore, improvements in mindfulness have been found to mediate between formal mindfulness practice and increases in psychological wellbeing (Carmody & Baer, 2008), indicating that symptom reduction and improved wellbeing are consequential of increased mindfulness, which is the result of mindfulness practice.

Psychological wellbeing is a multifaceted concept which, at its most basic level, refers to positive mental states such as happiness and life satisfaction (Robertson, 2018). Anxiety, on the other hand is a feeling of unease, worry or fear that ranges from mild to severe (National Health Service, 2020). Most people feel anxiety at certain times, which is normal, however when symptoms are ongoing and severe it can have a significant negative impact on quality of life (Olatunji et al., 2007). Unsurprisingly, levels of anxiety have been found to be inversely correlated with measures of wellbeing (Malone & Wachholtz, 2018), as people living with it are often unable to live the life they would like to (Swift et al., 2014). There is an increasing body of literature supporting mindfulness training, such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), as a means to improve wellbeing and anxiety symptomology. Numerous systematic reviews and meta-analyses demonstrate that these interventions lead to clinically significant increases in wellbeing and reduction in anxiety in the general population (Gu et al., 2016; Heckenberg et al., 2018). Reviewers stress the robustness of these results, in that the positive effects are maintained at follow-ups, do not change in relation to publication date, or number of sessions (Hofmann et al., 2010). Individual studies in sport-specific contexts have similar findings. Foster ( 2017) found a significant direct effect of mindfulness on both sport-specific wellbeing and global wellbeing. Similarly, retired Iranian football players have been found to report reduced stress, anxiety and depression and improved psychological wellbeing following an MBSR program (Norouzi et al., 2020). This evidence, along with the multifariousness of experimental cohorts that have been tested, suggests that mindfulness training is an efficacious, effective and flexible tool to improve wellbeing and anxiety within therapeutic frameworks.

Research assessing mindfulness outside of therapeutic frameworks, such as MBSR and MBCT, although less vast, is also positive. In 2018 Blanck et al. identified and reviewed 18 controlled trials assessing the efficacy of stand-alone mindfulness exercises in non-clinical populations. They found positive reductions on anxiety when compared to controls, with small to medium effect sizes, which remained significant when corrected for potential publication bias. According to the reviewers, "this demonstrates that the mere, regular performance of mindfulness exercises is beneficial, even without being integrated in larger therapeutic frameworks" (Blanck et al., 2018, pp. 25).

However, in real-life settings non-clinical populations are unlikely to engage with mindfulness via in-person training programmes. Caution should therefore be taken to avoid generalizing these results to cohorts that engage with mindfulness through different mediums. Indeed, a rapidly rising medium by which the general population are engaging with mindfulness is via smartphone applications (Economides et al., 2018). Due to the recent advancement of these applications, less is known about the efficacy of these mediums; however, some randomised controlled trials (RCT) have demonstrated positive effects. For instance, Economides et al. ( 2018) compared an introductory mindfulness meditation program, delivered via the Headspace app, to a psychoeducational audiobook control. Both interventions effectively reduced stress; yet only the mindfulness app improved irritability, affect and stress resulting from external pressure. Similar results were found by Walsh et al. ( 2019) who compared mindfulness training to cognitive training, both delivered via smartphone apps. They found that participants who engaged with the mindfulness app reported significantly more positive changes in subjective wellbeing, namely mood improvement, reduced stress and greater attentional control. These trials suggest that smartphone apps such as Headspace are an effective medium to deliver mindfulness training and that engaging with them positively influences wellbeing and anxiety symptomology. However, given the finite number of studies in this area, caution should be taken when interpreting this information. More trials, along with stringent reviews, are needed before full confidence can be had as to whether the findings are robust.

How Does Mindfulness Practice Relate to Rock-Climbing?

It appears evident that mindfulness is a well-established concept in the context of mental health. However, what is perhaps more surprising is that mindful practice is also rooted within the rock-climbing community. Many authors such as Arno Ilgner ( 2003) have written about mindfulness training as a way to improve climbing ability by increasing focus, motivation, and overcoming fears. Clinical specialists that work with competitive rock-climbers have also noted the observational benefits of integrating mindfulness training for sport-performance. Anna Enright, for example, is a psychiatric clinical nurse specialist who incorporates training to focus on breath, body awareness, and visualising peak performance in her work with youth climbing teams. Enright ( 2016, para.4) describes climbing as an "inherently mindful activity... If it is challenging, we lose focus and forget to scan ahead, breathe and allow our body to direct us... If mindful, one can observe this is happening and using the breath, the eyes, and the feel of the holds can help shift the focus back to the present climb". Such observations have also been recorded by healthcare organisations such as the National Health Service (NHS). According to the NHS ( 2020) rock-climbing alleviates the symptoms of mental health problems by keeping you focused, clearing your mind of outside worries, and helping you to build your confidence and self-esteem. Upon analysis, this recount reflects characteristics of Shapiro et al.'s ( 2006) aforementioned components of mindfulness. Specifically, remaining focused and clearing the mind of worries appears to map onto the components of attention and attitude, respectively. This indicates that rock-climbing offers a unique combination of physical and mental health benefits; as of yet, these have not been empirically validated. Evidence that rock-climbing promotes the development of psychological skills is not merely anecdotal, however. Young and Knigth ( 2014), for example, demonstrated that elite rock-climbers display a high rate of robust mental skill that allows them to remain present in the moment and perform under high stress conditions. Furthermore, experienced athletes scored significantly higher on measures of coping skill than leisure and novice athletes, suggesting a correlation between engagement in high-risk sports and psychological skills (Young & Knigth, 2014). It has been suggested that this is due to the nature of extreme sports such as rock-climbing, in that they require robust psychological skills to navigate unpredictable and adverse sport environments (Smith et al., 1995). The ability to remain present and in control in spite of fear can mean the difference between success and failure (Rooney, 2017).

In relation to mindfulness skills specifically, there is a distinct lack of research. Following a rigorous literature search one relevant study was identified, which explored the relationship between mindfulness and life satisfaction in rock-climbers and the general population (Steinberg, 2011). Analyses revealed that the rock-climbers had higher endorsements of mindfulness, positive affect and life satisfaction; and revealed a correlation between mindfulness, psychological wellbeing and rock-climbing. According to Steinberg ( 2011, pp.62), "The significant endorsement of mindfulness by the rock-climbers in this study provides statistical evidence for the potential benefit of using rock climbing as an activity to help facilitate mindfulness". Indeed, one possible explanation of Steinberg's finding is that the high endorsement of mindfulness is consequential of rock-climbing. Thus, based on the reviewed research demonstrating that mindfulness practice promotes wellbeing, if rock-climbing embodies mindfulness practice then rock-climbing should promote psychological wellbeing (see Fig. 1a). This theory is consistent with the evidence demonstrating that engagement with high-risk sports promotes a robust psychological skillset (Rooney, 2017; Smith et al., 1995; Young & Knigth, 2014); however, it is not the only explanation for Steinberg's findings. The other possibility is that mindfulness and engagement with rock-climbing have a common causal factor, such as a facet of personality. Meta-analyses have indicated that low neuroticism is associated with both mindfulness (Hanley & Garland, 2017) and engagement with high-risk sports (McEwan et al., 2019) such as rock-climbing. Therefore, rock-climbing and mindfulness may be independent consequences of low neuroticism, with this predicting wellbeing (see Fig. 1b). As of the time of writing, no empirical research had been conducted attempting to determine the nature of the relationship between rock-climbing and mindfulness, thus highlighting a striking gap in the psychological literature.

Conceptual illustrations of the possible relationships between rock-climbing, mindfulness and wellbeing. Note. ( a) and ( b) illustrate the possible explanation of Steinberg's ( 2011) findings discussed in this background of this paper

Purpose of the Current Study

This purpose of this study was to explore the relationship between rock-climbing, mindfulness and wellbeing in a non-clinical sample. The majority of research has focused on the benefits of mindfulness training for wellbeing, anxiety and rock-climbing performance, revealing a distinct lack of research as to the potential mental benefits of rock-climbing. And, while Steinberg ( 2011) has asserted that rock-climbing may facilitate mindfulness, at the time of writing this had not been empirically investigated. Hence, an aim of this experiment was to fill this gap in the literature by assessing whether participation in rock-climbing would increase measures of mindfulness when compared to a control group. Based on the evidence demonstrating that mindfulness practice improves wellbeing and anxiety symptomology, this study also aimed to investigate how participation in rock-climbing would affect these variables. This was achieved by exploring changes in measures of mindfulness, anxiety and wellbeing following an 'intervention', which for the purposes of this study is defined as participation in a mindfulness exercise followed by either rock-climbing or a control activity. To the best of my knowledge, this was the first controlled study to investigate the relationship between mindfulness and rock-climbing.

Methods

Participants

Due to the lack of previous research an a priori power analysis could not be performed. Instead, recruitment estimations were informed by Luttenberger et al.'s ( 2015) study of bouldering and depressive symptomology which found a significant medium effect size according to Cohen's d with 47 participants. In the current study 68 participants were recruited using two opportunity samples, advertised via posters and social media posts. Climbing abilities ranged from complete-beginners ("never having climbed") to advanced-beginners ("having climbed once or less a year"); and experience using mindfulness apps ranged from "never" to "once a month". Eligible participants were over the age of 18 and physically able to participate in the activities described in the procedure. Additional eligibility criteria were included for participants in the bouldering cohort to minimise the risk of harm. As such, participants were pre-screened and not invited to participate in the bouldering activity if they reported a history of epilepsy, panic attacks, or scored above clinical 'caseness' for anxiety or depression in the Hospital Anxiety and Depression Scale (see materials). Written informed consent was obtained from all participants at T0 and T1. All participants were debriefed following participation.

Procedure

This study used a quasi-experimental design in which the independent variable was group allocation: bouldering versus control. The control sample were required to participate in regular strength & conditioning (S&C) training and thus were recruited through the University of Nottingham (UoN) sports teams. As such, random allocation was not possible. The three dependent variables (mindfulness, wellbeing and anxiety) were collected at two timepoints: baseline, a week prior to the intervention (T0); and follow-up, immediately after the intervention (T1). Participants that met the exclusion criteria were screened out following collection of T0 data. The intervention consisted of a mindfulness activity, completed by all participants, followed by engagement in either a climbing or control activity. This study was approved by the UoN School of Psychology ethics committee and a full risk assessment was completed.

Mindfulness Activity

The purpose of the mindfulness activity was to set the intention of mindful participation, which has been identified as a principal component of mindfulness (Shapiro et al., 2006). Participants were seated in a quiet room with no distractions in group sizes ranging from 7 to 30 individuals. They were instructed to listen to three 3-min auditory guided meditations selected from the Headspace app, as at the time of writing Headspace was the only evidence-based mindfulness app available, had been downloaded more than 64 million times and was the highest scoring mindfulness-based app according to the Mobile Application Rating System (Mani et al., 2015). The meditations were called "Breathe", "Body Scan" and "Refresh" and were chosen to encapsulate Kabat-Zinn's ( 1994) core elements of mindfulness. The meditations were played from the researcher's laptop with a 1-min break between each; the order of presentation did not vary between groups so as not to introduce confounding variables. This activity took 11-min in total.

Climbing Activity: Bouldering

Indoor bouldering is a form of rock-climbing whereby people climb on artificial climbing structures (up to 4.5 m in height) without a rope. Bouldering walls offer a variety of routes that vary in difficulty, which allows people of different fitness levels to easily boulder together without being underchallenged or overstrained. The bouldering activity took place at the Nottingham Climbing Centre (NCC) in four groups of 7-13 participants. Prior to attending participants signed a waiver and completed a bouldering induction, allowing them to boulder as unsupervised adults. The bouldering activity consisted of warming-up exercises led by the researcher, who is a qualified Climbing Wall Instructor; followed by 1-h of unsupervised bouldering. The researcher was present at all times however only offered instruction relating to safety guidelines.

Control Activity: Strength & Conditioning (S&C)

To be eligible to partake in this activity participants had to attend S&C training as part of a sports team, as the researcher was not qualified to conduct this activity. The S&C training involved using gym-equipment as part of a regular programme to improve sport performance over time. Exercise has been shown to increase wellbeing therefore this activity, which requires similar levels of exertion as bouldering, was identified as a suitable control. The S&C activity took place at the David Ross Sports Village (DRSV) in one group of 30 and lasted 1-h. The researcher was not present for this activity.

Measures

Questionnaires were administered on Qualtrics ( http://www.qualtrics.com) and complied with general data protection regulations. The initial questionnaire completed at T0 (see supplementary material) collected demographical information, to gather relevant sample characteristics such as climbing experience; and screening information, to assess suitability for the bouldering activity. The following measures, along with a unique identification code to match the questionnaires, were collected at T0 and T1:

Hospital Anxiety and Depression Scale (HADS)

The HADS is a 14-item instrument designed to measure the levels of anxiety (HADS-A) and depression (HADS-D) that a person is experiencing (Snaith & Zigmond, 1986). Items are scored from 0 to 3, with items 1, 3, 5, 6, 7, 9, 10 and 11 being reversed scored. Scores below 7 indicate normal levels of anxiety and depression, scores of 8-10 indicate borderline symptoms, and scores above 11 indicate clinically significant symptoms. A literature review indicated that the HADS is highly correlated with other commonly used questionnaires and verified both the HADS-A (Cronbach's α = .83) and HADS-D (Cronbach's α = .82) were reliable measures of symptom severity (Bjelland et al., 2002). Therefore, this current study used the HADS-A as a measure of anxiety; and enlisted both subscales to pre-screen participants in the bouldering cohort. The score of each subscale ranges from 0 to 21, with scores of 11 or above indicating clinical 'caseness'; a term meaning symptomology is severe enough to be regarded as needing a clinical intervention. Thus, a score of 11 or above in the HADS-A or HADS-D was used as a cut-off to minimise risk to participants in the bouldering activity.

State Mindfulness Scale for Physical Activity (SMS-PA)

The SMS-PA is a 12-item measure that is used to assess the specific experience of mindfulness in physical activity (Cox et al., 2016). 6-items assess state mindfulness of the mind, which refers to an awareness of thoughts and emotions; and 6-items assess state mindfulness of the body, which represents being present in one's physical experience. Items are scored from 0 to 4, with higher scores indicated higher endorsement of mindfulness. Initial validity tests have indicated that the SMS-PA provides reliable estimates of mental (Cronbach's α = .89), physical (Cronbach's α = .90), and overall mindfulness (Cronbach's α = .90) at test and retest (Cox et al., 2016). As of the time of writing, the SMS-PA was the only available measure that facilitated the examination of state mindfulness in a physical activity context (Cox et al., 2016) and was therefore selected as a suitably sensitive measure of mindfulness in the current study.

The Flourishing Scale (FS)

The FS is an 8-item instrument used to assess core aspects of psychological wellbeing; see supplementary materials for items and scoring. It provides a single measure of self-perceived wellbeing in important areas such as relationships, self-esteem, purpose and optimism (Silva & Caetano, 2013). Items are scored from 0 to 7, with higher scores indicating stronger psychological resources and strengths. Validity tests have indicated the FS has good psychometric integrity, scores highly on estimates of reliability (Cronbach's α = .87) at test and retest and is strongly associated with other psychological wellbeing scales (Diener et al., 2009). It has been established as a viable measure for assessing wellbeing in student samples (Howell & Buro, 2015); and therefore, was selected as an appropriate measure of wellbeing for the current study.

Analyses

Data analyses were conducted using IBM SPSS Statistics software, version 26. Intervention methods were used to investigate within- and between- group differences for measures of anxiety, mindfulness and wellbeing; effect sizes were calculated according to Cohen's d. Following this, a multiple linear regression (MLR) analyses was then conducted for dependent variables whereby change scores varied significantly between groups. This was done to assess how much of the variance was accounted for by group condition. Finally, analyses were repeated in a sensitivity analysis whereby the same exclusion criteria were applied to the control and boulder groups. All fixed effects were similar so these are reported only briefly below.

Results

Sample

Of the 68 participants that completed the baseline questionnaire 59 were included in the main analysis and 56 were included in the sensitivity analysis. Participants in the bouldering and control groups did not differ significantly in mindfulness experience or climbing experience; however, the groups did differ significantly in age and gender (see Table 1). Flow of participants, including reasons for exclusion and dropout, are presented in Fig. 2.

Table 1 Characteristics, descriptive statistics & correlations, and linear model predictors of mindfulness of the full analysis sample

Flow chart of participants

Preliminary Analyses

Prior to analyses the dependent variables were tested for internal consistency, measured by Cronbach's α. All the variables demonstrated high reliability at T0 (mindfulness: α = .73; anxiety: α = .78; wellbeing: α = .93); however, at T1 only anxiety and wellbeing demonstrated high reliability (mindfulness: α = .67; anxiety: α = .86; wellbeing: α = .93). Following this, single scores of mindfulness, anxiety and wellbeing were calculated at T0 and T1 for each participant. Each variable was then verified to see if parametric tests were suitable to use on the data. These preliminary analyses revealed that none of the variables violated the assumption of homogeneity of variances or the assumption of sphericity. One participant in the control group was identified as an extreme outlier and was therefore excluded from the analyses. Tests of normality indicated that mindfulness was not in violation of the assumption of normality, however wellbeing and anxiety were. A logarithmic transformation of wellbeing, reported as log(wellbeing), corrected for this violation. Transformations were unable to correct for normality in anxiety; however, values of kurtosis and skewness indicated this would not impact on the validity of the results when analysed using a robust parametric test (Schmider et al., 2010). As such, all the measures were analysed using a mixed ANOVA as this is a powerful test requiring smaller sample sizes and minimises family-wise error. It is important to note that the logarithmic transformation of wellbeing reversed the direction of the relationship; therefore, a negative relationship from log(wellbeing) at T0 and T1 represents an increase in wellbeing.

Mixed ANOVA

Within-group comparisons were conducted to investigate whether the bouldering and control activities had caused a change in mindfulness, wellbeing and anxiety. Between-group comparisons were conducted to investigate whether the bouldering had affected any of the variables more than the control activity.

Mindfulness

There was a significant main effect of time, F(1, 57) = 22.74, p = .000, r = .53, with contrasts revealing that mindfulness was significantly greater at T1 than T0, F(1, 57) = 22.74, p = .000, r = .53. There was no significant main effect of group condition, F(1, 57) = .005, p = .942, r = .01, indicating that mindfulness scores were similar for participants in the bouldering and control groups. There was a significant interaction effect between time and group condition F(1, 57) = 10.77, p = .002, r  = .34. This effect indicates that the increase in mindfulness differed in the boulder and control groups. To break down this interaction, contrasts compared mindfulness at each time point to average mindfulness, across the boulder and control participants.

These contrasts revealed significant interactions when comparing participants' scores in the boulder and control groups to T0 compared to T1, F(1, 57) = 10.74, p = .000, r = .34. The interaction graph (see Fig. 3a) shows that although mindfulness increased in both groups, this increase was more pronounced in the boulder condition.

Within- and between- group comparisons of the main analysis for ( a) mindfulness, ( b) anxiety, and ( c) log(Wellbeing). Note. Bars represent one standard error of the mean

Anxiety

There was no significant main effect of time, F(1, 57) = 2.59, p = .113, r = .21, nor was there a significant effect of group, F(1, 57) = 1.32, p = .255, r = .15. This indicates that anxiety scores were similar for both participants in the bouldering and control groups. There was no significant interaction between time and group condition, F(1, 57) = 1.19, p = .279, r = .14, indicating that change in anxiety did not differ between the groups. See Fig. 3b for the interaction graph.

Wellbeing

There was a significant main effect of time on log(wellbeing), F(1, 57) = 15.60, p = .000, r = .46, with contrasts revealing that log(wellbeing) was significantly greater at T1 than T0, F(1, 57) = 15.60, p = .000, r = .46. There was no significant main effect of group condition, F(1,57) = .158, p = .693, r = .05, indicating that log(wellbeing) scores were similar for participants in the bouldering and control groups. There was no significant interaction between time and group condition, F(1, 57) = 1.85, p = .179, r = .18, however. This indicates that increases in log(wellbeing) did not differ between the groups. See Fig. 3c for the interaction graph.

Regression Analysis

The between-group comparisons revealed that mindfulness was the only measure in which change scores varied significantly between groups. Therefore, a MLR analysis was conducted on mindfulness at T1 to assess whether the condition effect remained when baseline levels of mindfulness were controlled for. Prior to this, preliminary analyses were conducted on mindfulness at T1, mindfulness at T0 and group condition to verify whether an MLR was suitable to use on the data. These revealed that none of the variables violated the assumptions of normality, linearity and multicollinearity; and indicated there were no extreme outliers. Table 1 presents the means, standard deviations and bivariate correlations between the core variables included in the analysis. As expected, the correlation between mindfulness at T0 and mindfulness at T1 was positive and significant.

To examine whether mindfulness at T1 was related to group condition when participants' baseline mindfulness was controlled for, a block entry (set-wise) regression analysis was performed. Mindfulness at T0 was entered into block 1 and group condition was entered into block 2. The analysis revealed that mindfulness at T0 accounted for a significant amount of the variance in mindfulness at T1, R ² = 28%, F(1, 58) = 22.43, p < .001. As expected, mindfulness at T0 was positively associated with mindfulness at T1, indicating that higher levels of mindfulness at T0 were associated with higher levels of mindfulness at T1. The addition of group condition in block 2 while controlling for baseline mindfulness explained an additional significant amount of the variance in mindfulness at T1, R ² = 33%, F(1, 57) = 4.45, p = .04. This variable was an independent predictor of mindfulness at T1, as can be seen in the summary of the model depicted in Table 1.

Sensitivity Analysis

Sensitivity analyses were conducted whereby the same exclusion criteria were applied to the control and boulder groups. All fixed effects for both the mixed ANOVA and MLR were similar to those reported for the main analyses in direction, magnitude and statistical significance (see Table 2).

Table 2 Mixed ANOVA results, descriptive statistics & correlations, and linear model predictors of mindfulness of the sensitivity analysis sample

Discussion

The aim of this experiment was to explore the relationship between rock-climbing and mindfulness in a controlled design. This was achieved by assessing how participation in bouldering affected measures of mindfulness, wellbeing and anxiety when compared to a control group undertaking a similar physical activity. As predicted, mindfulness increased significantly in the bouldering group only. The results regarding wellbeing and anxiety symptomology, however, were not consistent with the hypotheses in so far as no significant differences were found between the bouldering and control activity. This study provides the first evidence that rock-climbing increases mindfulness and has demonstrated that a single 1-h session does not affect measures of wellbeing and anxiety when compared to a similar physical activity.

Previous research has demonstrated a high rate of robust mental skills in rock-climbers (Young & Knigth, 2014); conjected to be a consequence of the need to remain present and in control in unpredictable environments (Smith et al., 1995). The findings of this study provide support for this conjecture in so far as the bouldering activity was found to be predictive of mindfulness, a psychological skill of awareness and attention (Shapiro et al., 2006); even when controlling for participants' baseline levels of mindfulness. This provides strong support for Steinberg's ( 2011) assertion that rock-climbing could be used as an activity to help facilitate mindfulness, as well as claims that rock-climbing clears and focuses the mind (NHS, 2020). Furthermore, it demonstrates that rock-climbing embodies mindful practice, as has previously been observed by clinical specialists and authors of sport-performance programmes (Enright, 2016; Ilgner, 2003).

In contrast, the current findings are inconsistent with the extant of research demonstrating that mindfulness practice promotes wellbeing and reduces anxiety (Blanck et al., 2018; Gu et al., 2016; Heckenberg et al., 2018), in so far as the increase in mindfulness in the bouldering cohort was not accompanied by greater changes in wellbeing and anxiety. This may be a reflection of the sample characteristics, in that both groups reported high levels of wellbeing and participants with a clinically relevant level of anxiety were excluded from the study. As such, there is not sufficient reason to expect significant changes in these measures. Furthermore, it is worth considering that a single 1-h session of bouldering is not a sufficient duration for mindfulness practice to affect these measures. Interventions for generalized anxiety disorders (NICE, 2019); trials investigating rock-climbing as a treatment for depression (Luttenberger et al., 2015; Stelzer et al., 2018); and research assessing the efficacy of mindfulness interventions are conducted for a minimum of 8 weeks. Therefore, the short duration and exclusion criteria of may have limited the findings of this study.

Theoretical & Practical Implications

This is the first controlled study to investigate the relationship between rock-climbing and mindfulness. The results provide novel evidence that rock-climbing increases mindfulness which encourages speculation as to the mechanism by which this may occur. One conjecture is that both mindfulness and rock-climbing promote "flow"; a state of mind believed to occur during optimal human experience (Wright et al., 2006). In positive psychology, a flow state is the mental state in which a person performing an activity is fully involved, energetically focused, and completely absorbed in the enjoyment of the process (Csikszentmihalyi, 1988). Mindfulness and challenge-skills such as rock-climbing are believed to create a flow state by forcing an individual to live in the present moment, not worry, and perform an activity because it is intrinsically rewarding (Csikszentmihalyi et al., 2014). Therefore, the state of mind a person experiences while rock-climbing may be synonymous to that of mindfulness. Flow is considered to reflect optimal experience and, fundamentally, promote overall life satisfaction, which one could consider as an explanation for the high levels of life satisfaction reported by rock-climbers in Steinberg's ( 2011) study. In 2018, Šimleša et al. proposed the 'Flow Engine Framework', a cognitive model to explain how this psychological phenomenon works. Exploring rock-climbing and mindfulness within the context of models such as these is an intriguing direction for future research to take and will have implications for the development of therapeutic rock-climbing programmes.

Indeed, the results of this current study alongside Steinberg's ( 2011) findings indicate that rock-climbing is an effective, efficacious, and ecologically valid tool to increase mindfulness. This indicates that engagement with rock-climbing promotes the development of robust psychological skills important for confidence, academic success, and overall wellbeing (Galli & Gonzalez, 2015). In this sense rock-climbing could be considered to be a protective factor; which in this context refers to an activity that helps an individual deal more effectively with stressful events (Sarkar & Fletcher, 2014). Practically this has implications with regard to the future implementation of rock-climbing as a resilience-building activity as well as the potential integration of rock-climbing within therapeutic frameworks. The potential of this within both clinical and non-clinical populations should be considered by future research, however caution should be taken as to which clinical populations this is be applied to. According to Farias and Wikholm ( 2016) mindfulness meditation has potentially damaging effects in around 5% of people, which is likely due to underlying trauma. Many psychiatric illnesses are rooted in trauma, and people often cope with this by drawing on a wide range of distracting mechanisms; mindfulness involves stopping all these mechanisms at once, which can be distressing and induce severe panic and anxiety (Ransford, 2015).

Strengths of the Research

A major strength of this study is that, unlike previous research in this area, it adopted a quasi-experimental design with a stringent and appropriate control condition. S&C training is used by elite climbing athletes to improve their performance (Phillips et al., 2012) and is therefore appropriate as a tool to engage the same muscles at a similar intensity to rock-climbing. Furthermore, both the bouldering and S&C training were conducted in groups. This removed potentially confounding variables from the study, such as social interaction and an- / aerobic respiration, and therefore the change in mindfulness can be confidently implicated to the rock-climbing activity.

Another strength of this study is that the analysis sample had no or minimal rock-climbing experience. As higher endorsement of psychological skills and mindfulness have been reported in rock-climbers (Steinberg, 2011) and athletes in other high-risk sports (Young & Knigth, 2014), omission of experienced climbers ensured that the sample was more likely to accurately represent mindfulness of young adults within the general population. In addition to this, low neuroticism has been associated with both mindfulness (Hanley & Garland, 2017) and engagement with high-risk sports (McEwan et al., 2019). While measures of personality facets were not measured, it is hoped that omission of individuals that regularly engage with mindfulness or high-risk sports protected against recruiting an unusual sample with lower neuroticism than young adults within the general population.

Limitations & Future Directions

Several notable limitations constrain the conclusions that can be drawn from this study. First, due to time and resource constraints, the researcher decided to recruit a stringent control group rather than randomly allocating participants. According to Schulz ( 2000) random allocation is the only method that eliminates selection and confounding biases by ensuring comparison groups are on equal footing at study onset. Nevertheless, the strengths of adopting an appropriate and stringent control sample are considered to outweigh the limitations of random allocation for this study. Another contributor of potential bias was the lack of concealment of group condition; this was not possible as the study was planned and conducted by one researcher. Furthermore, the researcher was present for the bouldering activity but not control activity and could therefore could have potentially influenced the bouldering group to participate in a more mindful way. This had the potential to introduce bias and inflate effect sizes (Schulz et al., 1995), however given the intention of mindful participation was set for both the bouldering and control group prior to the activities this is considered unlikely by the researcher.

It is also important to note the potential limitations arising due to the sample. Firstly, the sample included mostly students; therefore, the results may not generalise to other age groups and educational backgrounds. Secondly, there was a significant gender-ratio disparity between the bouldering and control groups; due to the lack of randomisation. While Tihanyi et al. ( 2016) have reported no gender difference in body awareness and mindfulness in physical activity, other studies indicate there may be subtle gender differences to facets within mindfulness (Alispahic & Hasenbegovic-Anic, 2017; Cathcart et al., 2014). The potential bias introduced by these subtle gender differences was not controlled for within this study. However, initial validation of the SMS-PA has indicated it is a reliable measure of mindfulness in both males and females (Cox et al., 2016).

Despite these limitations this experiment provides evidence that rock-climbing has practical implications within positive psychology and mental health. Firstly, it adds to the existing literature in support of physical activity to increase wellbeing in young adults; and secondly, it provides the first evidence that bouldering can effectively increase mindfulness in a healthy sample of young adults. Future research should aim to independently replicate these findings in light of the limitations discussed above. In this way a fully randomized, concealed and longitudinal trail incorporating age, gender and personality facets within the analysis would be an appropriate next step for future research. Furthermore, researchers could take the direction to replicate this study in clinical samples or explore the findings within the context of a cognitive model of flow.

Data Availability

The dataset generated during and analysed during the current study are available in the figshare repository, with identifier https://doi.org/10.6084/m9.figshare.13239077.v1.

References

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Code Availability

Qualtrics software was used to create questionnaires. Data was analysed using IBM SPSS Statistics software (version 26).

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Affiliations

Nottingham Climbing Centre, University of Nottingham, Nottingham, UK

Katherine A. Wheatley

Corresponding author

Correspondence to Katherine A. Wheatley.

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Ethics Approval

This study was approved by the School of Psychology, University of Nottingham ethics committee (No. S1234) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Written informed consent was obtained from all individual participants included in the study.

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# data[].attributes.attachment_link.title
Exploring the relationship between mindfulness and rock-climbing: a controlled study

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Mindfulness is a meditative practice that has received increasing attention within positive psychology as an effective tool to increase wellbeing and decrease anxiety. Previous research has demonstrated that rock-climbers have a higher endorsement of mindfulness and life satisfaction than the general population; yet to date, no research has empirically explored the relationship between mindfulness and rock-climbing.

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