Continuing Education
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Psychopharmacology: 4+1=5: Atypical Neuroleptic Update/Dan Egli |
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Exercise as a Therapeutic Modality: Adapting Psychological Treatments to Holistic Science and 21st Century Consumerism/Lori Huett |
Exercise as a Therapeutic Modality:
Adapting Psychological Treatments to Holistic Science and 21st Century Consumerism
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“The need for creative courage is in direct proportion to the degree of change the profession is undergoing.” - Rollo May Changes in managed care coverage and a corresponding breakdown in the doctor-patient relationship have propelled Americans to gather more information about their illnesses and to discover ways to treat their maladies most efficiently and effectively. In the last decade, consumer actions have resulted in a surge of “alternative” therapies that concurrently acknowledge and address the mind and body. Alternative treatment is defined as “interventions not taught widely in U.S. medical and/or graduate schools and not generally available in U.S. hospitals or clinics” (Studdert et al., 1998, p.1610). Since such treatments are so widely used, they are no longer viewed by consumers or providers as an “alternative” to traditional methods. Thus, a name change accompanies their popularity, and these treatments are now referred to as “complementary” therapies (Qualife, 1999). These treatments include acupuncture, acupressure, massage therapy, nutritional counseling, relaxation training, meditation, yoga, and movement therapy. A common philosophy supporting these forms is that the mind and body are interdependent systems that influence therapy outcome. A national survey published in the New England Journal of Medicine (Eisenberg et al., 1998) shows that an estimated 34% of Americans (61 million) reported using at least one complementary therapy in the past year. One-third of this group saw providers of alternative medicine an average of 19 sessions at $27.60 per visit. In 1997 alone, Americans made 425 million visits to providers of complementary treatment. This figure exceeds the amount of visits in that same year to U.S. primary care physicians. Annual expenditures for complementary treatments are estimated at 13.7 billion, with three-quarters of that amount being paid completely out of pocket. This figure exceeds the 12.8 billion spent annually for conventional hospitalizations and physicians’ visits in the United States. Although no comparisons have been computed for annual expenditures for number of sessions to psychologists (and other mental health practitioners) versus complimentary therapists, extrapolations from the medical data suggest similar trends for other treatments based on the medical model. New treatment modalities develop from consumers’ repudiation of the philosophy underlying the traditional medical model, which supplies the foundation for current medical and psychological practices. Specifically, the traditional medical approach is based on the doctor being the expert authority on diagnosis, pathology, and prescription, with his/her expertise being administered to a relatively passive sick person, called the “patient” (Millenson, 1995). This model is also based on the myopic treatment of supposed static and distinct parts (e.g., the stomach, the “mind”). This paradigm is relevant to the diagnostic and treatment practices among psychologists trained in most clinical and counseling programs. However, as clients have become advocates for their own health and treatment in the face of managed care capitation policies, their roles and expectations as consumers of health services have changed. The appeal to complementary modes of treatment include clients’ requests that practitioners spend more time collecting data, diagnosing symptoms as an interaction of “cofactors,” viewing the body as a whole, and tailoring treatment to their particular individual needs instead of administering standardized protocols to target specific symptoms supposedly in isolation (Barash, 1993). Millenson (1995) reminds us that the traditional health care system resists change. Specifically, medicine and psychology are “industries practiced within an entrenched social institution with many vested interests which resist change” (p. 4). However, consumers, who play a major part in shaping health programs and policies, are demanding that certain alterations be made regarding services. If traditional health care providers do not adjust to market changes, the demand for their services will lessen along with their profits. With little or no demand for traditional therapies, a steady supply of practitioners or services is profitless (APA Task Force, 1976). Thus, our myopic view of treating parts, organs, and minds is still at a stage of crisis management (Millenson, 1995). Our clients, through their spending on mind-body remedies, acknowledge the deficits inherent in the philosophical underpinnings of the traditional healing approach, which splits parts from the whole person. Unfortunately, traditional scientific experimentation, with its operation of hypothetical-deduction can never lend itself to resolving the mind-body schism (see Chiesa, 1994 for complete argument). However, it is not practical to contend or ignore this issue in our application of “medical” or “psychological” treatments. Specifically, the outcome of dualism for psychology is as outrageous as requesting that our clients leave their bodies in the waiting room for the duration of the session since their “minds,” and not bodies, are the subject of interventions. Given that the health care profession is witnessing dramatic changes in how its services are utilized, health care professionals face the need to show creativity at a high level. Rollo May (1975) states, “The need for creative courage is in direct proportion to the degree of change the profession is undergoing” (p. 22). May’s words are worth considering as they pertain to changes in the practices of psychotherapy, especially heeding the fact that psychologists function to assist individuals who experience difficulties in adapting or modifying their behavior to fit the changes that occur in their surroundings (e.g., families, financial stability). If psychologists are to implement the content of what they preach, then certain socio-economic demands must be realized, instead of denied, and specific responses must be made. A parallel to certain complimentary medical interventions and within the purview of psychotherapy may be using physical movement as a tool in working with individuals and groups. I first pondered the potential for this type of work while I was an undergraduate practicum student in New York. At this time, I was interning at Metropolitan Hospital Center, which included Harlem in its catchment area. As a Caucasian female who was raised in the Midwest, I encountered considerable cultural differences with the adolescents in the After-School Program with whom I worked. Exercise and dance serendipitously served as equalizers. It was through the exchange of choreography and sharing of music that our cultural differences could safely be explored, commonalities were realized, and rapport was established. Although I certainly was not cognizant of this aspect then, perhaps body movement also served the function of “getting out of our heads”—and away from cognition, which is the level stereotypes are processed and maintained. Additionally, I have worked with several individuals who have expressed interests in beginning exercise programs and who even request to stretch or perform some physical movements during our sessions. Although this is not the main focus of our sessions, several of my clients have specified desires to include exercise into their daily regimens. Since most of my work has been audio or video-taped for supervision and training purposes, I have not investigated or pursued this option of assisting clients to begin their exercise regimens by using it either as a backdrop or tool in therapy (e.g., conducting a session while taking a brisk walk). In addition, given the litigious nature of our society, I have also pondered the necessary alterations to standard treatment consent forms that will need to be made prior to engaging in this type of work. My interest in the integration and incorporation of exercise into psychotherapy only continues to burgeon with each yoga class that I take (especially Bryan Kest’s classes in Santa Monica). In these classes, instructors introduce themes of “aligning intention with one’s actions,” “getting out of one’s head by focusing on the present moment,” and simultaneously “strengthening one’s body, spirit, and mind.” The physical focus seems to magnify such positive meditations, and I invariably depart from class thinking that Bryan Kest, among others who teach the philosophies of yoga, are doing what we psychologists do in therapy—but on a grander scale (i.e., the services seem widely available and more freely utilized). There is an abundance of scientific research and anecdotal evidence which support the benefit and utility of integrating exercise into the psychotherapeutic process (Berger, 1984; Doyne et al., 1987; Jin, 1992; Martinsen, 1990; Martinsen et al., 1989; Morgan, 1985; North et al., 1990; Orwin, 1974; Petruzzello et al., 1990; Simons et al., 1985). Clinical and sports psychologist, Hays (1994), identifies that engaging clients in physical exercise provides a nice background for the foreground of therapeutic work. Like free association or systematic desensitization, exercise may similarly be considered a tool for treatment. For example, physical activity may invoke or magnify additional issues or other modalities related to changes desired around presenting problems. Moreover, exercise enacts metaphors of “moving forward” from perceived debilitating states, such as depression or anxiety, during which individuals often feel immobile. Exercising in therapy also responds to consumers’ interests in more active styles of treatment (that is, clients’ desires to be treated as capable humans in lieu of “sickly” patients who passively await remedy, as well as clients’ needs to be treated as a whole spiritual, physical, and mental being instead of an “ego” or “cognition”). Finally, exercise as a treatment modality relates to Rollo May’s (1975) reflection on the need for creativity in the face of market changes and particular consumer demands for psychotherapy. By engaging our clients in physical activity in addition to verbal discourse, we can also capitalize from the effects of multi-modal treatment and process affective and cognitive experiences non-verbally. Since our clients experience the world with their bodies (i.e., non-verbally) as well as with their “minds” (i.e., verbally), an incorporation of both experiential aspects allows us to approximate more closely the essence of our clients’ issues. Again, the logic of working with more of the client’s modalities includes expectations for increased adherence, positive treatment effects, and generalization since one more facet of the client’s life is included. For example, a client who is depressed, anxious, and abusing substances is not engaged just on a cognitive level. There are somatic or physical components to all of these experiences. Given the interdependence of the mind and body, exercise allows us to target more fully a client’s problems than verbal treatment alone (Buffone, 1980). In addition, exercise, itself, possesses many qualities that enhance psychological functioning and lend to improvements in affect, cognition, physiological functioning, behavioral change, and interpersonal involvement. For example, exercise corresponds to improvements in mood, better sleeping patterns, improved eating habits, decreases in smoking, drinking, drugging, increased physical energy, better concentration and memory functioning, weight loss, and improvements in body and corresponding self image (Berger, 1984; Blair et al., 1985). Peele and Brodsky (1991) identify that “positive feelings and desires are more motivating for people to change than negative ones” (p. 165). Positive changes in affect are shown to be associated with exercising (Folkins & Sime, 1981; Morgan, 1985; Sonstroem & Morgan, 1989). Additionally, since exercise is also incompatible with several anti-health behaviors, it provides a venue for developing problem solving, learning relapse prevention strategies, and building a lifestyle that is diametrically opposed to the client’s current dysfunctional one. Again, this lends to a contextual conceptualization of the etiology and maintenance of problem behavior and trend towards comprehensively targeting issues as opposed to assuming the traditional myopic focus on problems that are deemed sole “clinical.” Although relatively few studies ask for clients’ feedback to evaluate the various elements of comprehensive treatment programs, within the various therapy programs that include exercise with verbal psychotherapy and ask for client input, individual reports indicate that clients value the exercise portion of their treatment (Martinsen, 1990; Martinson & Medhur, 1989). These contrast the belief that depressed clients abhor strenuous physical activity, a perspective often shared among mental health practitioners (Martinson & Medhur, 1989). Martinsen (1990) identifies that there is no empirical evidence to support this notion. In fact, depressed individuals rank exercise as the most important element in comprehensive treatment programs. However, studies of people with mental health problems indicate that they are less physically active than the general public (Burbach, 1997). In another study comparing yoga with traditional medical and psychological treatments for chronic pain, depression, and anxiety, Allen and Steinkohl (1987) report that yoga produced more favorable outcomes as rated by clients. Furthermore, the group of geriatric patients in this study chose to facilitate and continue their own physical program beyond the six-month duration of the research. Like with other treatment groups surveyed, clients in this study, and others, rank exercise above traditional verbal forms of psychotherapy, group treatment, and medication (Martinsen & Medhur, 1990; North et al., 1990). Exercise is frequently experienced as more “central to change” than the conventional dialogue of individual and group therapy. The popularity of exercise and perception of its effectiveness in targeting clinical issues is demonstrated across populations (e.g., depressed, anxious, etc.), cohorts (e.g., adolescents, geriatrics), and exercise modalities (e.g., yoga, walking, running, swimming). Several studies examine the beneficial outcomes of exercise with children whose attention spans for verbal discourse is limited (Allen, 1980; Bass, 1985; Elsom, 1980; Evans, 1981; Shipman, 1984; Hinckle, 1992). Other studies have shown that exercise with adolescent offenders gives structure and allows for a lessening of inhibitions around sharing feelings and communicating (Hilyer et al., 1982). In addition, Brody (1995) identifies that a combination of structured and unstructured movements help small children who are unable to express their feelings verbally, adults who have lost touch with their feelings, and elderly who are sometimes lonely, depressed, or too confused to talk. Thus, the suitability of exercise to psychotherapy has broad qualifications. With its variations in intensity, type (e.g., endurance training, strength-building), and contexts, exercise may be done with all ages and for the purpose of targeting a myriad of problem areas. No age limits or restrictions for the positive psychological and physical benefits of exercise can be identified (Wolinsky et al., 1995). These findings provide additional rationale for considering more active styles of therapy, especially since the typical sedentary lifestyle is associated with detrimental behaviors that include increased risk-taking, smoking, alcohol/substance use, and the consumption of junk food (Burbach, 1997). These behaviors are even more significant for individuals with mental health concerns who present for psychotherapy; these behaviors are often concomitant to clinical problems (e.g., depression, anxiety, addictions). At present, the American Council on Exercise (ACE), as well as several other recognized organizations, currently offers the fitness certification of “clinical exercise specialist” to health professionals who seek to include exercise into their medical and/or psychological treatments. Such certification provides therapists with the basic competency in which to integrate physical activity into the clinical work that they do with their clients. In particular, psychologists over other health practitioners, such as physical therapists, personal trainers, and medical doctors, possess discrete skills and advantages for helping people incorporate exercise into treatment and their lifestyles. Psychologists’ clinical skills of problem diagnosis, assessment of readiness to change, selecting and applying appropriate interventions, and monitoring feedback are relevant to assisting people to identify and follow-through with modification plans. Specifically, the skills of assisting individuals to communicate their needs to others, identify and accept rewards for goals achieved, anticipating and removing barriers, and providing accurate instruction and rationale have been shown to contribute to greater adherence to exercise (Clearing-Sky, 1988; Dzewaltowski, 1989). Goal-setting, behavioral contracting, record keeping, reinforcement, and exercise with clients (i.e., modeling and practice effects) in the initial weeks are also shown to contribute to improved adherence rates to exercise and therapeutic programs (Brown, 1986). Barrow et al. (1987) surveyed psychologists on the topic of their own exercise practices, beliefs, and prescriptions for treatment. Of 196 respondents, 140 (71.43%) reported engaging in regular exercise. A majority of these psychologists indicate “improved regulation in mood” and “increases in physical energy and mental stamina” as reasons why exercise is beneficial for the typical sedentary occupation of psychologists whose work requires intense concentration and emotional stamina. As a result of observing the benefits derived from their own exercise practices and the empirical research supporting the “physical” and “psychological” benefits of physical activity, an increasing number of psychologists are engaged in evaluating and making recommendations to their clients in the areas of diet and physical exercise (Royak-Schaler & Feldman, 1984). Exercise within treatment is most commonly discussed by therapists for the perceived value of symptomatic reduction, especially the alleviation of depression, anxiety, and management of tension, stress, and anger. Additional reasons for prescribing exercise include that physical activity may provide clients with a sense of mastery, improve physicality, enhance the therapeutic relationship, and promote social skills (Burks & Keeley, 1989). Yet, in Barrow’s (1987) survey, bodily benefits account for 22% of the reasons that respondents give for addressing exercise with their clients in therapy. Given this percentage, it seems that many therapists do not see their work as pertaining to the body. Instead, most practitioners believe that clients come to treatment to discuss psychological ailments and not physical, exercise-related ones. Although many therapists acknowledge the interconnectedness of these domains, many maintain a separation of these spheres in terms of only illuminating the emotional and cognitive via verbal discourse. However, despite a burgeoning focus on the body and philosophy of considering the whole individual in lieu of supposed isolated parts (e.g., the “mind”), psychotherapy primarily remains a verbal enterprise. Given consumer trends toward holistic, complimentary treatments, our clients realize that few of us experience our physical and psychological symptoms as quite so dichotomous. Every psychological or emotional issue has some physical and biological component and vice versa. If psychology is going to not only survive but also thrive in the context of managed care restrictions and changes in consumer spending, then we are doing to have to alter the deliverance of our services to meet these needs. This challenges older styles of conducting therapy, especially methods that are based entirely on verbal discourse. Given the empirical and anecdotal support for its broad applicability to the treatment of many clinical conditions and the myriad of qualities that exercise possesses for facilitating therapy process and outcome, physical activity is a promising area for psychological interventions. Given consumer demand and spending patterns regarding mind-body therapies, managed care interests for integrating services, and the responsibility psychologists bear to treat clients’ problems with efficient technology, exercise is a viable treatment that deserves further attention. References American Council on Exercise. (1997). Personal trainer manual. San Diego, C.A.: ACE. Allen, J. (1980). Jogging can modify disruptive behaviors. Teaching Exceptional Children, 12, 66-70. Allen, K., & Steinkohl, R. (1987). Yoga in a geriatric mental clinic. Activities, Adaptation, and Aging, 9, 61-68. APA Task Force on Health Research. (1976). Contribution of psychology to health research. American Psychologist, 31, 263-274. Barasch, M. (1993). The healing path: A soul approach to illness. New York: Putnam Publishers. Barrow, J., English, T., & Pinkerton, R. (1987). Physical fitness training: Beneficial for professional psychologists? Professional Psychology: Research and Practice, 18, 66-70. Bass, C. (1985). Running can modify classroom behavior. Journal of Learning Disabilities, 18, 160-161. Berger, B. (1984). Stress reduction through exercise: The mind-body connection. Motor Skills: Theory into Practice, 7, 31-46. Berger, B. & Owen, D. (1988). Stress reduction and mood enhancement in four exercise modes: Swimming, body conditioning, hatha yoga, an fencing. Research Quarterly for Exercise and Sport, 59, 148-159. Blair, S., Jacobs, D., & Powell, K. (1985). Relationships between exercise or physical activity and other health behaviors. Public Health Reports, 100, 172-180. Brody, J. (1995, October 20). Dance shoes replace therapist’s couch. Union News (Springfield, M.A). 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Exercise adherence and patients’ evaluation of physical exercise in a comprehensive treatment programme for depression. Nordic Journal of Psychiatry, 43, 411-415. May, R. (1975). The courage to create. New York: W.W. Norton & Company. McEntee, D. & Halgin, R. (1996). Therapists’ attitudes about addressing the role of exercise in psychotherapy. Journal of Clinical Psychology, 52, 48-60. Millenson, J. (1995). Mind matters: Psychological medicine in holistic practice. Seattle, WA: Eastland Press. Mimmack, F. (1999). Personal interviews (5/21; 6/28; 9/02). Denver, Colorado. Morgan, W. (1985). Affective beneficence of vigorous physical activity. Medicine and Science in Sports and Exercise, 17, 94-100. North, T., McCullagh, P., Tran, Z. (1990). Effects of exercise on depression. Exercise and Sport Sciences Reviews, 18, 379-415. Orwin, A. (1974). Treatment of a situational phobia: A cause for running. British Journal of Psychiatry, 125, 95-98. Peele, S. & Brodsky, A. (1991). The truth about addiction and recovery: The life program for outgrowing destructive habits. New York: Simon & Schuster. Petruzzello, S., Landers, D., Hatfield, B., Kubitz, K., & Salazar, W. (1991). A meta-analysis on the anxiety-reducing effects of acute and chronic exercise. Sports Medicine, 11, 143-182. Qualife Wellness Community (June, 1999). Information presented by staff during a biannual “Wellness weekend workshop,” Denver, Colorado. Royak-Schaler, R. & Feldman, R. (1984). Health behaviors of psychotherapists. Journal of Clinical Psychology, 40, 705-710. Shipman, W. (1984). Emotional and behavioral effects of long-distance running on children. In Running as therapy (Sachs & Buffone eds.). Lincoln, N.B.: University of Nebraska Press. Simons, A., Epstein, L., McGowan, C., & Kupfer, D. (1985). Exercise as a treatment for depression: An update. Clinical Psychology Review, 5, 553-568. Sonstroem, R. & Morgan, W. (1989). Exercise and self-esteem: Rationale and model. Medicine and Science in Sports and Exercise, 21, 329-337. Studdert, D., Eisenberg, D., Miller, F., Curto, D., Kaptchuk, T., Brennan, T. (1998). Medical malpractice implications of alternative medicine. Journal of the American Medical Association, 280 (18), 1610-1615. Wolinsky, F., Stump, T., & Clark, D. (1995). Antecedent and consequences of physical activity and exercise among older adults. The Gerontologist, 35, 451-462. |
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