Activity for Mental Health

Brad Bowins

• Editorial: Academic Press
• Año: 2020
• ISBN:
  9780128209561
• Categoría: Psychologie
• Categoría: Klinische Psychologie

Activity For Mental Health explores all activities, including physical, social, natural, cognitive, art/hobby and music as a means to both preventing and treating mental illness. This book not only reviews evidence-based research behind activity, but also explores how these forms of activity can treat mental illnesses. First, the reader is introduced to the concepts of Formal Behavioral Activation Therapy (BAT) and informal activity as an effective treatment option. Case examples aid in connecting the benefits to real life scenarios. Following the introduction, each activity is introduced in separate chapters, including physical, social, natural, cognitive, art/hobby and music.

This book will provide researchers and clinicians the information needed to help customize treatment options for their patients suffering from mental illness.

• Evaluates the effectiveness of Behavioral Activation Therapy (BAT) as compared to existing psychotherapy treatments
• Advocates creative activities to improve depression and anxiety
• Includes multiple case studies detailing experiences with BAT and other therapies
• Examines the relationship between physical activity and the nervous system, thus reducing sympathetic system stress responses
• Explores the role of cognitive activity in predicting cognitive health

Chapter 1

Introducing activity (therapy) for mental health

Abstract

Activity is defined to clarify what can be included. The reasons for the author’s interest in Behavioral Activation Therapy (BAT) and focus here on informal activity are expressed. When applied to treat mental illness, activity qualifies as activity therapy. Experience with informal and formal versions of therapeutic approaches is presented, to show how informal approaches are both robust and applicable to many more mental health consumers than formal approaches, thereby setting the stage for informal activity therapy. The power of activity is demonstrated by presenting a client treated by the author, who suffered from such severe depression that months of inpatient care with multiple interventions failed to produce any appreciable benefit, whereas activity resolved her depression.

Keywords

Activity therapy; Activity; Behavioral Activation Therapy; Depression; Mental health; Mental illness

This is a book about activity focused strictly on mental health. In contrast to physical health where the emphasis is only on physical activity, several forms of activity apply to mental health. There are physical, social, nature, mental (cognitive), art/hobby, music, and potentially other forms of activity on their own or combined. This book explores the evidence for how these diverse forms of activity impact mental health and the reasons why this occurs—the rationale. Although the term “activity” appears clear, it is always helpful to start with a definition. Merriam-Webster defines activity as: the quality or state of being active. From this, we go to their definition of active: characterized by action rather than by contemplation or speculation, as in an active life. One level further, we get to their definition of action: a thing done. From this multilevel definition, we can say that activity is the quality or state of getting something done!

My interest in the role that activity plays in mental health requires some information about my background. I am a psychiatrist with over 25   years of experience, mostly focused on adults, although I have treated older adolescents in a university student health setting. My practice is in Ontario, Canada, a setting that still allows psychiatrists to provide diverse forms of psychotherapy—in many or most parts of the world the role of a psychiatrist has been reduced to assessments and brief mostly medication focused visits. Through experience, I have found that the best approach is often an eclectic one, tailoring treatment to the needs of the person. As a medical doctor (psychiatrist trained in medicine), I tend to apply the term patient, but most therapists say client, so I will go with the latter term. My clients typically benefit from this eclectic approach involving diverse forms of psychotherapy and/or medication as required. In addition to this practice, I conduct research, mostly theoretical, being the founder of the Centre for Theoretical Research in Psychiatry and Clinical Psychology (psychiatrytheory.com), an online resource. My research interests are also eclectic, frequently motivated by what I see in my own practice, and I ensure that the theories generated fit well with clinical realities, and of course the research evidence. Within the context of eclectic therapy and research, and also in line with my active lifestyle, I became intrigued by Behavioral Activation Therapy (BAT). There are different versions of this therapeutic approach, but all focus on increasing reinforcing activity. Applying it to my clients, I quickly noted the benefits. A key principle of this form of therapy is approaching sources of reinforcement in a graded fashion, starting with the least difficult and progressing to more challenging ones. The topic of formal BAT is addressed in the Behavioral Activation Therapy chapter. This book is not about BAT, but instead covers activity and informal activity therapy when applied to treat mental illness.

Regarding informal and formal versions of therapy, I came to appreciate the value of the former. Early on, I practiced more formal cognitive therapy focused on thoughts, giving clients homework type assignments and going over this work during sessions. What happens though when you give many or most people homework? Right, they do not do it or only partially do it as many teachers rapidly discover. I would arrive at the waiting room to see a client feverishly writing things down that were supposed to be done during the week, and many just came in making excuses for why it was not completed. At the university health service, students had to be “screened” to see if they would do the cognitive therapy assignments. Consider this for a second—university students screened to see if they, of all people, could and would do assignments! Then it hit me, a real epiphany: why bother with formal versions for most people and instead apply informal versions adjusting them to the capacity, needs, and interests of the client. I noted that this more informal approach works very well in the context of eclectic psychotherapy, and I have never looked back. Informal and formal are really on a continuum of formality, so I do provide therapy consistent with BAT to some clients.

One example of a more formal BAT intervention demonstrating the value of activity therapy involves a client (I'll try and stick to this term but forgive me for the odd slip) in a state of profound depression. We will refer to her as Jennifer, not her real name. Jennifer's family doctor contacted me in a state of desperation over what to do with her, having tried medication and lengthy supportive talks, but nothing worked. A few months prior, she had been released from a local major psychiatric hospital after a stay of several months. Staff at the hospital tried multiple medications, many rounds of electroconvulsive therapy (ECT) inducing seizures essentially, and various talk approaches. For the most part, she remained depressed, unmotivated, and inactive staying in bed. The ECT gave her severe headaches, but not much else. Fairly confident that she was not going to take her life, and at least able to get out of bed for some needs, the hospital staff released her to the care of her husband and teenage daughter. At this point began the family doctor's stress over what to do.

Her husband brought Jennifer to our first session, and several following ones. She looked depressed and lethargic with limited speech, and almost always in response to what I asked; no spontaneous conversation. It did not take a psychiatrist to diagnose severe depression. Thankful that I knew about activity therapy and was experienced with its application, I informed her that the only way she was going to get out of this was by one thing, and one thing only—activity. In response to blank looks from both her and her husband, I explained that physical, mental, and social activity is at least as effective as medication for severe depression (I was hoping more effective given the abysmal response to date). Although skeptical, both agreed to try it. I laid out a plan of graded activity starting with the most basic. Regarding physical activity, she was to get out of bed, despite not wanting to, even if all this entailed was sitting on the living room couch. Social activity meant responding to her husband and daughter. For mental activity, she was going to read anything, even the headlines on a newspaper or part of a young child's book. For the first few sessions, she struggled with this basic level of activity, but then was okay with it.

Consistent with the graded level approach, we moved to walking within the house for physical activity, listening to phone messages from friends and relatives for social activity, and reading the easiest to absorb articles or even just a paragraph. Again, there was some delay, but faster than at the start. We progressed to walks in the yard with her husband and/or daughter, conversing with people including returning calls (not initiating), and longer reading sessions. Next came walks along the street with her husband and/or daughter, initiating conversation and calls to friends and family, and reading more involved material. As she achieved progressively more advanced and challenging forms of physical, social, and mental activity, she began to feel better and more energized given the reinforcement derived from those activities, and was less hopeless and downcast. Carefully note that there was no focus on getting her to feel better first, it was all about activity. Within 6   months, she was coming to sessions on her own, walking several blocks without company, and seeing friends she had not interacted with for well over a year. She claimed that she no longer felt depressed. For Jennifer, it was all about the activity that got her out of the depression, to the great relief of her family doctor, relatives, and friends. We will return to Jennifer's story from time to time, as there are some intriguing aspects that inform regarding activity. Suffice it to say at this point, that after several years she remains free of significant depression, and is actively managing her own life, with no further hospital admissions.

If activity was able to get Jennifer out of such a profound depression when every other approach failed miserably, then it is reasonable to believe that activity can be helpful for milder depression and also optimizing mental health in those lacking any mental illness, who we often say are normal, but what is normal? Hence, we will just say, those lacking any formal mental illness. However, as reasonable as this sounds, it is important to consider the research evidence for activity and mental health, as well as the rationale for this. For most of the book, we will consider various types of informal activity and not formal BAT. When activity is applied to treat mental illness, it represents activity therapy. Regarding how to approach the evidence, I will supplement research results with select client examples, and even personal anecdotes. Hopefully, this “eclectic” approach will be of greater interest to all who are curious about how activity can impact mental health, and also inform more broadly, than a strictly factual review. We will now look at the various forms of activity that can be applied to your clients if you are a mental health professional, and your own life whether you have mental illness or are free of such problems. The research evidence presented will emphasize more recent studies and those that shed light on diverse aspects of the given form of activity relevant to mental health. Evidence levels for each form of activity will be summarized in the concluding chapter. Although it might be tempting to set up a hierarchy of activity types based on this, it is important to appreciate that evidence can shift depending on research funding and interest; hence, each form covered will be presented in an egalitarian fashion. The very important question of why the particular form of activity benefits mental health, the rationale, will also be addressed in each chapter, with general reasons across all types of activity in the conclusion, drawn on my theoretical research background. Appreciate that in reading this you are increasing, or maintaining, your mental activity!

Chapter 2

Physical activity

Abstract

The chapter starts with a discussion of evidence-based medicine and how the quality of the evidence is frequently not considered. A summary of research approaches including experimental, longitudinal, and cross-sectional is provided in an accessible form, emphasizing the strengths and weaknesses. Cause and effect compared to correlation is discussed. Longitudinal, experimental, and cross-sectional evidence is covered in separate sections showing what each form contributes. The evidence is high quality in many instances strongly supporting the capacity of physical activity to treat mental illness and advance mental health in the general population. The chapter then progresses to how physical activity achieves this in terms of mediating and causal influences. Physical self-perceptions with associated changes in self-concept and the induction of pleasant feelings are robust mediating influences. Neurobiological and psychological causal influences apply, such as in the case of the latter, a distraction response style.

Keywords

Cross-sectional research; Distraction response style; Evidence-based medicine; Experimental research; Human evolution; Longitudinal research; Mental health; Mental illness; Physical activity; Self-perceptions

1. Longitudinal studies (correlational)
2. Experimental studies
3. Cross-sectional studies (correlational)
4. Mediating and causal influences
   1. Mediating influences
   2. Causal influences
5. Summary note
6. References

Humans evolved in hunting-gathering groups moving about in search of food and other resources. This way of life instilled in us a need for activity, in contrast to our sedentary chimpanzee, gorilla, and orangutan relatives, such that from at least a physical perspective, inactivity is equivalent to a health-related death sentence, according to the evolutionary anthropologist (Pontzer, 2017). Intuitively, it makes sense that mental health might also be implicated, if for no other reason than physical activity helps for physical health, and since body and mind are connected, physical health should somewhat translate into mental health. However, we cannot just assume this to be the case, instead we have to see what support is there for this proposition. In the current era, the term “evidence-based medicine” is encountered in virtually any conversation regarding treatments. Unfortunately, the quality of the evidence is often ignored, such as with antidepressants, where research bias overemphasized the number of studies showing a positive outcome for these medications and their efficacy or effectiveness in reducing or resolving depression. In reviewing the extensive research pertaining to physical activity and mental health, I note that studies are all over the map, so to speak, covering diverse aspects of this topic, and the quality does not always seem ideal. Hence, my mission, given that I have chosen to accept it, is to try and make sense of it all, and indicate how strongly the evidence supports the relationship between physical activity and good mental health.

A starting point in considering research evidence is to distinguish between different forms of research and highlight the limitations and strengths. Correlational studies look for a relationship between variables, but cannot tell us the direction of the relationship. For example, such a study might assess the physical activity level and how negative or positive the mood is, finding that higher physical activity is linked to better mood. What the study cannot say, though, is which variable caused the other. Maybe higher physical activity results in better mood, or better mood motivates more physical activity. Another limitation is that maybe a third variable is really accounting for the linkage, such as perhaps better income improves mood and also allows for physical activity. Correlational studies then demonstrate that two variables are related, but cannot prove in what direction, or whether another variable is responsible for the relationship.

The main limitation of correlational studies—not able to show the direction—is addressed by experimental research. Using our example of physical activity and mood, the level of physical activity is varied and the mood level is measured both prior to this activity and after, to see if any change occurs and in what direction. Possibly as physical activity increases, mood worsens as subjects become more tired. While it might appear that experimental studies are conclusive having solved the cause and effect of direction issue of correlational studies, there are several limitations, one being that the results might relate to the specific experimental circumstances and not be reproducible, either by chance or design. Without getting into the topic to any significant extent, a positive experimental result, such as demonstrating that increasing physical activity levels improves mood, will occur by chance about 5% of the time. Perhaps, the given experiment was one of those 5% false outcomes. Design flaws in the study introducing bias can also lead to false positive results. Maybe the experimenters, who interacted with the subjects, believe strongly that physical activity improves mood and somehow communicate that belief to subjects, leading them to rate their mood higher with increase...