Marys Medicine


Lifestyle and mental health

Lifestyle and Mental Health
Roger Walsh
Online First Publication, January 17, 2011. doi: 10.1037/a0021769 Walsh, R. (2011, January 17). Lifestyle and Mental Health. American Psychologist. Advanceonline publication. doi: 10.1037/a0021769 Lifestyle and Mental Health University of California, Irvine College of Medicine Mental health professionals have significantly underesti- the diseases exacting the greatest mortality and morbidity— mated the importance of lifestyle factors (a) as contributors such as cardiovascular disorders, obesity, diabetes, and to and treatments for multiple psychopathologies, (b) for cancer—are now strongly determined by lifestyle. Differ- fostering individual and social well-being, and (c) for ences in just four lifestyle factors—smoking, physical ac- preserving and optimizing cognitive function. Conse- tivity, alcohol intake, and diet— exert a major impact on quently, therapeutic lifestyle changes (TLCs) are underuti- mortality, and "even small differences in lifestyle can make lized despite considerable evidence of their effectiveness in a major difference in health status" (Khaw et al., 2008, p.
both clinical and normal populations. TLCs are sometimes as effective as either psychotherapy or pharmacotherapy TLCs can be potent. They can ameliorate prostate and can offer significant therapeutic advantages. Important cancer, reverse coronary arteriosclerosis, and be as effec- TLCs include exercise, nutrition and diet, time in nature, tive as psychotherapy or medication for treating some relationships, recreation, relaxation and stress manage- depressive disorders (Frattaroli et al., 2008; Pischke, Scher- ment, religious or spiritual involvement, and service to witz, Weidner & Ornish, 2008; Sidhu, Vandana, & Balon, others. This article reviews research on their effects and 2009). Consequently, there is growing awareness that con- effectiveness; the principles, advantages, and challenges temporary medicine needs to focus on lifestyle changes for involved in implementing them; and the forces (economic,institutional, and professional) hindering their use. Where primary prevention, for secondary intervention, and to em- possible, therapeutic recommendations are distilled into power patients' self-management of their own health.
easily communicable principles, because such ease of com- Mental health professionals and their patients have munication strongly influences whether therapists recom- much to gain from similar shifts. Yet TLCs are insuffi- mend and patients adopt interventions. Finally, the article ciently appreciated, taught, or utilized. In fact, in some explores the many implications of contemporary lifestyles ways, mental health professionals have moved away from and TLCs for individuals, society, and health professionals. effective lifestyle interventions. Economic and institutional In the 21st century, therapeutic lifestyles may need to be a pressures are pushing therapists of all persuasions toward central focus of mental, medical, and public health. briefer, more stylized interventions. Psychiatrists in partic-ular are being pressured to offer less psychotherapy, pre- Keywords: lifestyle, therapeutic lifestyle changes, mental scribe more drugs, and focus on 15-minute "med checks," health, psychopathology, cognitive capacities a pressure that psychologists who obtain prescription priv- ileges will doubtless also face (Mojtabai & Olfson, 2008).
he central thesis of this article is very simple: Health As a result, patients suffer from inattention to complex professionals have significantly underestimated the psychodynamic and social factors, and therapists can suffer importance of lifestyle for mental health. More spe- painful cognitive dissonance and role strain when they cifically, mental health professionals have underestimatedthe importance of unhealthy lifestyle factors in contributing shortchange patients who need more than what is allowed to multiple psychopathologies, as well as the importance of by mandated brief treatments (Luhrmann, 2001).
healthy lifestyles for treating multiple psychopathologies, A further cost of current therapeutic trends is the for fostering psychological and social well-being, and for underestimation and underutilization of lifestyle treatments preserving and optimizing cognitive capacities and neural (Angell, 2009) despite considerable evidence of their ef- fectiveness. In fact, the need for lifestyle treatments is Greater awareness of lifestyle factors offers major growing, because unhealthy behaviors such as overeating advantages, yet few health professionals are likely to mas- and lack of exercise are increasing to such an extent that the ter the multiple burgeoning literatures. This article there- World Health Organization (2008, para. 1) warned that "an fore reviews research on the effects and effectiveness of escalating global epidemic of overweight and obesity— eight major therapeutic lifestyle changes (TLCs); the prin- ‘globesity'—is taking over many parts of the world" and ciples, advantages, and challenges involved in implement-ing them; the factors hindering their use; and the manyimplications of contemporary lifestyles for both individuals Correspondence concerning this article should be addressed to Roger and society.
Walsh, Department of Psychiatry and Human Behavior, University of Lifestyle factors can be potent in determining both California College of Medicine, Irvine, CA 92697-1675. E-mail: physical and mental health. In modern affluent societies, Month 2011 American Psychologist 2011 American Psychological Association 0003-066X/11/$12.00Vol. , No. , 000 – 000 DOI: 10.1037/a0021769 tion can be therapeutic for multiple psychological andpsychosomatic disorders (Chiesa, 2009; Didonna, 2009;Shapiro & Carlson, 2009). Yet it can also enhance psycho-logical well-being and maturity in normal populations andcan be used to cultivate qualities that are of particular valueto clinicians, such as calmness, empathy, and self-actual-ization (Shapiro & Carlson, 2009; Walsh, 2011; Walsh &Shapiro, 2006).
Knowledge of TLCs can benefit clinicians in several ways. Utilizing TLCs may result in greater clinical flexi-bility and effectiveness and less role strain. It will beparticularly interesting to see the extent to which cliniciansexposed to information about TLCs adopt healthier life-styles themselves and, if so, how adopting them affectstheir professional practice, because there is already evi-dence that therapists with healthy lifestyles are more likelyto suggest lifestyle changes to their patients (McEntee &Halgin, 1996). There are also entrepreneurial opportunities.
Clinics are needed that offer systematic lifestyle programsfor mental health that are similar to current programs forreversing coronary artery disease (Pischke et al., 2008).
Roger Walsh
For societies, TLCs may offer significant community and economic advantages. Economic benefits can accruefrom reducing the costs of lifestyle-related disorders suchas obesity, which alone accounts for over $100 billion in exacting enormous medical, psychological, social, and eco- costs in the United States each year (World Health Orga- nomic costs.
nization, 2008). Community benefits can occur both di- Advantages of Therapeutic Lifestyle
rectly through enhanced personal relationships and service (Post, 2007) and indirectly through social networks.
Recent research demonstrates that healthy behaviors Lifestyle changes can offer significant therapeutic advan- and happiness can spread extensively through social net- tages for patients, therapists, and societies. First, TLCs can works, even through three degrees of separation to, for be both effective and cost-effective, and some—such as example, the friends of one's friends' friends (J. H. Fowler exercise for depression and the use of fish oils to prevent & Christakis, 2008, 2010). Encouraging TLCs in patients psychosis in high-risk youth—may be as effective as phar- may therefore inspire similar healthy behaviors and greater macotherapy or psychotherapy (Amminger et al., 2010; well-being in their families, friends, and co-workers and Dowd, Vickers, & Krahn, 2004; Sidhu et al., 2009). TLCs thereby have far-reaching multiplier effects (Christakis, can be used alone or adjunctively and are often accessible 2009; J. H. Fowler & Christakis, 2010). These effects offer and affordable; many can be introduced quickly, some- novel evidence for the public health benefits of mental times even in the first session (McMorris, Tomporowski & health interventions in general and of TLCs in particular.
Audiffren, 2009).
So what lifestyle changes warrant consideration? Con- TLCs have few negatives. Unlike both psychotherapy siderable research and clinical evidence support the follow- and pharmacotherapy, they are free of stigma and can even ing eight TLCs: exercise, nutrition and diet, time in nature, confer social benefits and social esteem (Borgonovi, 2009).
relationships, recreation, relaxation and stress manage- In addition, they have fewer side effects and complications ment, religious and spiritual involvement, and contribution than medications (Amminger et al., 2010).
and service to others.
TLCs offer significant secondary benefits to patients, such as improvements in physical health, self-esteem, andquality of life (Deslandes et al., 2009). Furthermore, some Exercise offers physical benefits that extend over multiple TLCs—for example, exercise, diet, and meditation—may body systems. It reduces the risk of multiple disorders, also be neuroprotective and reduce the risk of subsequent including cancer, and is therapeutic for physical disorders age-related cognitive losses and corresponding neural ranging from cardiovascular diseases to diabetes to prostate shrinkage (Hamer & Chida, 2009; Pagnoni & Cekic, 2007; cancer (Khaw et al., 2008; Ornish et al., 2008). Exercise is Raji et al., 2010). Many TLCs—such as meditation, relax- also, as the Harvard Mental Health Letter ("Therapeutic ation, recreation, and time in nature—are enjoyable and Effects," 2000, p. 5) concluded, "a healthful, inexpensive, may therefore become healthy self-sustaining habits (Di- and insufficiently used treatment for a variety of psychiatric donna, 2009).
Many TLCs not only reduce psychopathology but can As with physical effects, exercise offers both preven- also enhance health and well-being. For example, medita- tive and therapeutic psychological benefits. In terms of Month 2011 American Psychologist prevention, both cross-sectional and prospective studies emotional states, and caregiver distress (Christofoletti, show that exercise can reduce the risk of depression as well Oliani, Gobbi, & Stella, 2007; Deslandes et al., 2009).
as neurodegenerative disorders such as age-related cogni- Meta-analytic studies provide more fine-grained de- tive decline, Alzheimer's disease, and Parkinson's disease tails about the cognitive benefits of exercise for the elderly (Hamer & Chida, 2009; Sui et al., 2009). In terms of and offer four kinds of good news. First, the effects can be therapeutic benefits, responsive disorders include depres- large, reducing the risk of Alzheimer's disease by 45% and sion, anxiety, eating, addictive, and body dysmorphic dis- increasing cognitive performance by 0.5 SD (Hamer & orders. Exercise also reduces chronic pain, age-related cog- Chida, 2009). Second, though women may gain more than nitive decline, the severity of Alzheimer's disease, and men, everyone seems to benefit, including both clinical and some symptoms of schizophrenia (Colcombe & Kramer, nonclinical populations. Third, improvements extend over 2003; Daley, 2002; Deslandes et al., 2009; Stathopoulou, several kinds of psychological functions, ranging from Powers, Berry, Smits, & Otto, 2006).
processing speed to executive functions. Fourth, executive The most studied disorder in relation to exercise to functions, such as coordination and planning, appear to date is mild to moderate depression. Cross-sectional, pro- benefit most, a welcome finding given that executive func- spective, and meta-analytic studies suggest that exercise is tions are so important, and that both they and the brain both preventive and therapeutic, and in terms of therapeutic areas that underlie them are particularly age sensitive (Col- benefits it compares favorably with pharmacotherapy and combe & Kramer, 2003; Erickson & Kramer, 2009).
psychotherapy (Dowd et al., 2004; Sidhu et al., 2009). Both Finally, meta-analyses reveal the specific elements of aerobic exercise and nonaerobic weight training are effec- exercise that benefit cognition. Relatively short programs tive for both short-term interventions and long-term main- of one to three months in length offer significant benefits, tenance, and there appears to be a dose–response relation- though programs of six months or longer are more benefi- ship, with higher intensity workouts being more effective.
cial. There seems to be a threshold effect for session Exercise is a valuable adjunct to pharmacotherapy, and duration, because sessions shorter than 30 minutes—while special populations such as postpartum mothers, the el- valuable for physical health—yield minimal cognitivegains. Cognitive benefits are enhanced by more strenuous derly, and perhaps children appear to benefit (Hamer & activity and by combining strength training with aerobics Chida, 2008; Larun, Nordeim, Ekeland, Hagen, & Heian, (Colcombe & Kramer, 2003; Hertzog, Kramer, Wilson, & 2006; Sidhu et al., 2009).
Lindenberger, 2009). In short, research validates the words Possible mediating factors that contribute to these of the second U.S. president, John Adams, who wrote, "Old antidepressant effects span physiological, psychological, minds are like old horses; you must exercise them if you and neural domains. Proposed physiological mediators in- wish to keep them in working order" (Hertzog et al., 2009, clude changes in serotonin metabolism, improved sleep, as well as endorphin release and consequent "runner's high" Fortunately, even brief counseling can motivate many (Deslandes et al., 2009; Stathopoulou et al., 2006). Psycho- patients to exercise (Long et al., 1996), and the risks are logical factors include enhanced self-efficacy and self- minimal, although an initial medical exam may be war- esteem, interruption of negative thoughts and rumination ranted. Yet despite the many mental and medical benefits (Dowd et al., 2004), and perhaps the breakdown of mus- of exercise, only some 10% of mental health professionals cular armor, the chronic psychosomatic muscle tension recommend it. And who are these 10%? Not surprisingly, patterns that express emotional conflicts and are a focus of they are likely to exercise themselves (McEntee & Halgin, somatic therapies (Smith, 2000).
Neural factors are especially intriguing. Exercise in- creases brain volume (both gray and white matter), vascu- Nutrition and Diet
larization, blood flow, and functional measures (Erickson There is now considerable evidence of the importance of & Kramer, 2009; Hamer & Chida, 2009). Animal studies nutrition for mental health, and an extensive review of over suggest that exercise-induced changes in the hippocampus 160 studies suggests that dietary factors are so important include increased neuronogenesis, synaptogenesis, neuro- that the mental health of nations may be linked to them nal preservation, interneuronal connections, and BDNF (Go´mez-Pinilla, 2008). Given the enormous literature on (brain-derived neurotrophic factor, the same neurotrophic this topic, it is easy to feel overwhelmed. Therefore, the factor that antidepressants upregulate) (Cotman & Berch- following sections review this complex literature but also told, 2002).
distill easily communicable principles, because such ease Given these neural effects, it is not surprising that of communication strongly influences whether therapists exercise can also confer significant cognitive benefits (Mc- recommend and patients adopt such treatments (Duncan, Morris et al., 2009). These range from enhancing academic Miller, Wampold, & Hubble, 2009). Two major dietary performance in youth, to aiding stroke recovery, to reduc- components must be considered: food selection and sup- ing age-related memory loss and the risk of both Alzhei- mer's and non-Alzheimer's dementia in the elderly (Hamer & Chida, 2009; Quaney et al., 2009). Multiple studies showthat exercise is a valuable therapy for Alzheimer's patients For food selection, the key principles for TLCs are to that can improve intellectual capacities, social functions, emphasize a diet that Month 2011 American Psychologist 1. Consists predominantly of multicolored fruits and ern diets are often high in omega-6s and deficient in omega-3s vegetables (a "rainbow diet").
(Freeman et al., 2006).
2. Contains some fish (a "pescovegetarian diet"): Is this dietary deficiency associated with psychopa- Preference should be given to cold deep-seawater thology? Both epidemiological and clinical evidence sug- fish (e.g., salmon), which are high in beneficial gest that it is. Affective disorders have been the ones most omega-3 fish oils, while avoiding the four species closely studied, and epidemiological studies, both within with high mercury levels (shark, swordfish, king and between countries, suggest that lower fish consumption mackerel, and tilefish) (Oken et al., 2008).
is associated with significantly, sometimes dramatically, 3. Reduces excessive calories: For societies confront- higher prevalence rates of these disorders (Freeman et al., ing the "globesity" epidemic, reducing excess cal- 2006; Noaghiul & Hibbeln, 2003). Likewise, lower omega-3 ories offers both economic and public health ben- levels in tissue are correlated with greater symptom sever- efits (Delpeuch, Marie, Monnier, & Holdsworth, ity in both affective and schizophrenic disorders, a finding 2009). For individuals, reducing excess calories consistent with emerging evidence that inflammation may offers medical and neuroprotective benefits (Prolla play a role in these disorders (Amminger et al., 2010).
& Mattson, 2001). This neuroprotection is espe- However, epidemiological studies of dementia and omega-3 cially important in light of recent findings suggest- fatty acid intake are as yet inconclusive (Freeman et al., 2006).
ing that adult obesity may be associated with re- Epidemiological, cross-sectional, and clinical studies duced cognitive function, as well as reduced white- suggest that omega-3 fatty acid supplementation may be and gray-matter brain volume (Raji et al., 2010; therapeutic for several disorders. Again, depression has Wolf et al., 2007). Fortunately, pescovegetarian been the disorder most closely studied (Stahl, Begg, Weis- diets are low in calories.
inger, & Sinclair, 2008). Several meta-analyses suggestthat supplementation may be effective for unipolar, bipolar, Multiple human and animal studies suggest that pescoveg- and perinatal depressive disorders as an adjunctive, and etarian diets may prevent or ameliorate psychopathologies perhaps even as a stand-alone, treatment (Appleton, Rog- across the life span (Go´mez-Pinilla, 2008; Willis, Shukitt- ers, & Ness, 2010; Lin & Su, 2007), although at this stage, Hale, & Joseph, 2009). Such diets may enhance cognitive supplementation is probably best used adjunctively. Ques- and academic performance in children as well as ameliorate tions remain about optimal DHA and EPA doses and ratios, affective and schizophrenic disorders in adults. They also although one meta-analysis found a significant correlation offer neuroprotective benefits, as demonstrated by reduc- between dose and treatment effect, and a dose of 1,000 mg tions in the incidence of age-related cognitive decline, of EPA daily is often mentioned, which requires several Alzheimer's disease, and Parkinson's disease (Go´mez-Pi- fish oil capsules (Freeman et al., 2006; Kraguljac et al., nilla, 2008; Kang, Ascherio, & Groodstein, 2005; Morris, Evans, Tangney, Bienias, & Wilson, 2006). Several studies There are also cognitive benefits of supplementation.
of the Mediterranean diet—including a meta-analysis of 12 In infants, both maternal intake and feeding formula sup- prospective studies with over 1.5 million subjects—found plementation enhance children's subsequent cognitive per- reductions in the incidence of both Alzheimer's and Par- formance (Freeman et al., 2006; Go´mez-Pinilla, 2008; In- kinson's diseases (Sofi, Cesari, Abbate, Gensini, & Casini, nis, 2009). In older adults, fish and fish oil supplements 2008). Dietary elements that appear to be particularly neu- appear to reduce cognitive decline but do not seem effec- roprotective include fish, vegetables, and perhaps fruit, as tive in treating Alzheimer's disease (Fotuhi, Mohassel, & well as lower intake of animal fats (Gu, Nieves, Stern, Yaffe, 2009).
Luchsinger, & Scarmeas, 2010; Kang et al., 2005; Morris et The evidence on omega-3s for the treatment of other al., 2006). Of enormous public health importance are recent disorders is promising but less conclusive. Supplementa- findings suggesting that, owing to epigenetic factors, "the tion may benefit those with schizophrenia and Huntington's effects of diet on mental health can be transmitted across disease as well as those exhibiting aggression in both generations" (Go´mez-Pinilla, 2008, p. 575).
normal and prison populations. In children, omega-3s may reduce aggression and symptoms of attention-deficit/hy-peractivity disorder (ADHD; Freeman et al., 2006; Song & Growing evidence suggests that food supplements offer Zhao, 2007).
valuable prophylactic and therapeutic benefits for mental A particularly important finding is that fish oils may health. Research is particularly being directed to Vitamin prevent progression to first episode psychosis in high-risk D, folic acid, SAME (S-adenosyl-methionine), and—most youth. A randomized, double-blind, placebo-controlled of all—fish oil (Sarris, Schoendorfer, & Kavanagh, 2009).
study was conducted of 81 youths between 13 and 25 years Fish and fish oil are especially important for mental of age who had subthreshold psychosis. Administering fish health. They supply essential omega-3 fatty acids, espe- oil with 1.2 g of omega-3s once per day for 12 weeks cially EPA (eicosapentaenoic acid) and DHA (docosa- reduced both positive and negative symptoms as well as the hexaenoic acid), which are essential to neural function.
risk of progression to full psychosis. This risk was 27.5% Systemically, omega-3s are anti-inflammatory, counteract in controls but fell to only 4.9% in treated subjects. Par- the pro-inflamatory effects of omega-6 fatty acids, and are ticularly important was the finding that benefits persisted protective of multiple body systems. Unfortunately, mod- during the nine months of follow-up after treatment cessa- Month 2011 American Psychologist tion (Amminger et al., 2010). Such persistence has not phers echoed similar claims, and the romantic poet William occurred with antipsychotic medications, which also have Wordsworth (1807/1998, p. 307) famously described the significantly more side effects. Although coming from only absence of such a healing connection: a single study, these findings suggest another important Getting and spending, we lay waste our powers: prophylactic benefit of fish oils.
Little we see in Nature that is ours; With one exception, risks of fish oil supplementation We have given our hearts away . .
at recommended doses are minimal and usually limited tomild gastrointestinal symptoms. The exception occurs in Yet today we are conducting a global experiment in which patients on anticoagulants or with bleeding disorders, be- we increasingly spend our lives in artificial environments— cause fish oils can slow blood clotting. Such patients walled inside and divorced from nature. Within these na- should therefore be monitored by a physician.
ture-free settings, noise is often annoying, and lighting is Omega-3s modify genetic expression and as such are often artificial, of low intensity (often less than 10% of the early exemplars of a possible new field of "psychonutri- light intensity on sunny days), and composed of nonnatural genomics." Nutrigenomics is an emerging discipline that spectra and rhythms. As the burgeoning field of environ- uses nutrients to modify genetic expression (Gillies, 2007).
mental psychology demonstrates, the psychological costs Because genetic expression is proving more modifiable, of such settings can be wide-ranging. These costs include and nutrients more psychologically important than previ- disruptions of mood, sleep, and diurnal rhythms. Cognitive ously thought, psychonutrigenomics could become an im- costs include short-term impairment of attention and cog- portant field.
nition as well as long-term reduced academic performance Space limitations allow only brief mention of another in the young and greater cognitive decline in the elderly significant supplement, Vitamin D. Vitamin D is a multi- (Anthes, 2009; Higgins, Hall, Wall, Woolner, & Mc- purpose hormone with multiple neural functions, including Caughey, 2005; Ku¨ller, Ballal, Laike, Mikellides, & neurotrophic, antioxidant, and anti-inflammatory effects Tonello, 2006). Further psychological difficulties occur in (Cherniack, Troen, Florez, Roos, & Levis, 2009). Vitamin special populations such as those with Alzheimer's disease D deficiency is widespread throughout the population, es- and postsurgical patients (Anthes, 2009; Ulrich, 2006).
pecially in the elderly, and exacts a significant medical toll;several studies suggest associations with cognitive impair- Media Immersion and Hyperreality
ment, depression, bipolar disorder, and schizophrenia.
In the last half century, a further artificial dimension has Mental health professionals are therefore beginning to join been added. Increasingly, we now spend hours each day physicians in recommending routine supplementation (usu- immersed in a flood of multimedia stimuli, the neurological ally 600 units per day) and, where indicated, testing pa- impact of which we are only beginning to understand.
tients' Vitamin D blood levels and modifying supplement However, some researchers have already concluded that levels accordingly (Cherniack et al., 2009).
"the current explosion of digital technology not only is There are further benefits to supplementation and changing the way we live and communicate but also is pescovegetarian diets. First, they have multiple general rapidly and profoundly changing our brains" (Small & health benefits and low side effects. Second, they may Vorgan, 2008, p. 44). This is hardly surprising given that ameliorate certain comorbid disorders—such as obesity, the average American spends several hours a day watching diabetes, and cardiovascular complications—that can ac- television and increasing amounts of time with digital company some mental illnesses and medications. A diet media (Putnam, 2000). As Thoreau (1854, p. 85) lamented, that is good for the brain is good for the body. As such, people "have become the tools of their tools." dietary assessment and recommendations are appropriate Fortunately, television and digital media can some- and important elements of mental health care.
times be beneficial. Multiple meta-analyses show that al- though aggressive television content can certainly fosternegative attitudes and aggressive behavior, prosocial con-tent can foster positive behavior such as altruism (Mares & Imagine a therapy that had no known side effects, was readilyavailable, and could improve your cognitive functioning at zero Woodard, 2005; Preiss, Gayle, Burrell, Allen & Bryant, cost. Such a therapy has been known to philosophers, writers, and 2006). Likewise, digital immersion can benefit certain psy- laypeople alike: interacting with nature. Many have suspected that chological and social skills in children, as the massive nature can promote improved cognitive functioning and overall Digital Youth Project demonstrated (Ito et al., 2008).
well-being, and these effects have recently been documented.
However, media immersion can also exact significant (Berman, Jonides, & Kaplan, 2008, p. 1207) psychological and physical costs in both children andadults, and a novel vocabulary has emerged to describe For thousands of years, wise people have recommended multiple "technopathologies." Excessive media immersion, nature as a source of healing and wisdom. Shamans seek especially when combined with heavy work demands, can wilderness, yogis enter the forest, Christian Fathers retreat create psychological dysfunctions that include disorders of to the desert, and American Indians go on nature visionquests. Their experience is that nature heals and calms, attention: continuous partial attention and attention removes mental trivia, and reminds one of what really deficit trait matters (Walsh, 1999). Romantic and existential philoso- cognition: digital fog and techno-brain burnout Month 2011 American Psychologist overload: data smog and frazzing (frantic ineffec- Nature also offers the gift of silence. Modern cities tual multitasking) abound in strident sounds and noise pollution, and the days addiction: screen sucking and on-line compulsive when Henry Thoreau (1849/1921, p. 291) could write of silence as a "universal refuge . . a balm to our everychagrin" are long gone. Unfortunately, urban noise can and, of course, techno-stress (Small & Vorgan, 2008; exact significant cognitive, emotional, and psychosomatic Wehrenberg & Coppersmith, 2008).
tolls. These range, for example, from mere annoyance to Yet the full implications of contemporary media and attentional difficulties, sleep disturbances, and cardiovas- our divorce from nature may extend much further and cut cular disease in adults and impaired language acquisition in far deeper than individual stress and pathology. There is an children (Clark & Stansfeld, 2007). By contrast, natural exploding literature on their social effects (e.g., Bracken & settings offer silence as well as natural sounds and stimuli Skalski, 2010), and so powerful and pervasive is today's that attention restoration theory and research suggest are multimedia reality, that for philosophers such as Jean Bau- restorative (Berman et al., 2008).
drillard, it constitutes a hyperreality—a simulated life- As yet, studies of specific psychotherapeutic benefits world that seems more real than reality. So omnipresent are are limited, and the benefits are sometimes conflated with media-manufactured images and narratives, and so di- those of other therapeutic lifestyle factors. Though further vorced are we from the direct events they portray, that we research is clearly needed, immersion in nature does appear largely live in, believe in, and respond to this artificial to reduce symptoms of stress, depression, and ADHD and hyperreal world rather than the natural world itself (Tiffin to foster community benefits (Taylor & Kuo, 2009; Taylor, & Terashima, 2001).
Kuo, & Sullivan, 2001). In hospital rooms that offer views Evolutionary, Existential, and Clinical
of natural settings, patients experience less pain and stress, have better mood and postsurgical outcomes, and are ableto leave the hospital sooner (Devlin & Arneill, 2003; Ul- We have barely begun to research the many implications of rich, 2006). Consequently, nature may be "one of our most artificial environments, new media, hyperreality, and our vital health resources" (Maller et al., 2006, p. 52). Given divorce from nature. However, the problems they may pose the global rush of urbanization and technology, the need for can be viewed in multiple ways. Biologically, we may be mental health professionals to advocate for time in, and adapted to natural living systems and to seek them out. This preservation of, natural settings will likely become increas- is the biophilia hypothesis, and multiple new fields—such ingly important.
as diverse schools of ecology, as well as evolutionary, environmental, and eco- psychologies—argue for an inti-mate and inescapable link between mental health and the Of all the means which are procured by wisdom to ensure hap- natural environment (Esbjorn-Hargens & Zimmerman, piness throughout the whole of life, by far the most important is 2009). In existential terms, the concern is that "modern the acquisition of friends. (Epicurus, quoted in D. Gordon, 1999, man— by cutting himself off from nature has cut himself off from the roots of his own Being" (Barrett, 1962, p.
The idea that good relationships are central to both physical 126), thereby producing an existential and clinical condi- and mental well-being is an ancient theme, now supported tion generically described as nature-deficit disorder (Louv, by considerable research. Rich relationships reduce health risks ranging from the common cold to stroke, mortality, Clinicians harbor multiple concerns. Evolutionary and and multiple psychopathologies. On the positive side, good developmental perspectives suggest that children in envi- relationships are associated with enhanced happiness, qual- ronments far different from the natural settings in which we ity of life, resilience, cognitive capacity, and perhaps even evolved, and to which we adapted, may suffer developmen- wisdom (J. H. Fowler & Christakis, 2008; Jetten, Haslam, tal disorders, with ADHD being one possible example Haslam, & Branscombe, 2009). Analyses of different do- (Bjorklund & Pellegrini, 2002). Likewise, evolutionary mains of life indicate that quality of life is "dominated by theory and cross-cultural research suggest that for adults, the domain of intimacy" and that people with overt psy- artificial environments and lifestyles may impair mental chopathology have a lower quality of life "most particu- well-being and also foster or exacerbate psychopathologies larly in the domain of intimacy" (Cummins, 2005, p. 559).
such as depression (Buss, 2000).
These clinical observations can now be grounded in Therapeutic Benefits of Nature
the emerging field of social neuroscience, which suggeststhat we are interdependent creatures, hardwired for empa- Fortunately, natural settings can enhance both physical and thy and relationship through, for example, the mirror neu- mental health. In normal populations, these enhancements ron system (Cattaneo & Rizzolatti, 2009). So powerful is include greater cognitive, attentional, emotional, spiritual, interpersonal rapport that couples can mold one another and subjective well-being (Ho, Payne, Orsega-Smith, & both psychologically and physically. They may even come Godby, 2003; Pryor, Townsend, Maller, & Field, 2006).
to look more alike, as resonant emotions sculpt their facial Benefits also occur in special populations such as office muscles into similar patterns—a process known as the workers, immigrants, hospital patients, and prisoners Michelangelo phenomenon (Rusbult, Finkel, & Kumashiro, (Maller, Townsend, Pryor, Brown, & St Leger, 2006).
Month 2011 American Psychologist Not surprisingly, good relationships are crucial to of clients' relationships clearly warrants a central place in psychotherapy. Multiple meta-analyses show that they ac- mental health care.
count for approximately one third of outcome variance, Recreation and Enjoyable Activities
significantly more than does the specific type of therapy(Duncan et al., 2009), and that "the therapeutic relationship Through experiences of positive emotions people transform them- is the cornerstone" of effective therapy (Norcross, 2009, p.
selves, becoming more creative, knowledgeable, resilient, socially 114). As Irvin Yalom (2002, p. 34) put it, the "paramount integrated, and healthy individuals. (Fredrickson, 2002, p. 123) task is to build a relationship together that will itself be- Involvement in enjoyable activities is central to healthy come the agent of change." Ideally, therapeutic relation- lifestyles, and the word recreation ("re-creation") summa- ships then serve as bridges that enable patients to enhance rizes some of the many benefits (Fredrickson, 2002). In life relationships with family, friends, and community.
behavioral terms, many people in psychological distress The need may be greater than ever, because social suffer from low reinforcement rates, and recreation in- isolation may be increasing and exacting significant indi- creases reinforcement. Recreation may overlap with, and vidual and social costs. For example, considerable evidence therefore confer the benefits of, other TLCs such as exer- suggests that, compared with Americans in previous de- cise, time in nature, and social interaction. Recreation can cades, Americans today are spending less time with family involve play and playfulness, which appear to reduce de- and friends, have fewer intimate friends and confidants, and fensiveness, enhance well-being, and foster social skills are less socially involved in civic groups and communities and maturation in children (Lester & Russell, 2008) and (McPherson, Smith-Lovin & Brashears, 2006; Putnam, perhaps also in adults (G. Gordon & Esbjorn-Hargens, 1995, 2000). However, there is debate over, for example, 2007). Recreation can also involve humor, which appears whether Internet social networking exacerbates or compen- to mitigate stress, enhance mood, support immune function sates for reduced direct interpersonal contact and over the and healing, and serve as a mature defense mechanism methodology of some social surveys (Fischer, 2009). Yet (Lefcourt, 2002).
there is also widespread agreement that "the health risk of Further recreational activities include art and other social isolation is comparable to the risks of smoking, high aesthetic pleasures, which have long been employed for blood pressure and obesity. . [while] participation in self-healing. For example, the great 19th-century philoso- group life can be like an inoculation against threats to pher John Stuart Mill— one of history's outstanding intel- mental and physical health" (Jetten et al., 2009, pp. 29, 33).
lectual prodigies—spent his childhood force-feeding him- Beyond the individual physical and mental health self with facts. However, when at 20 he fell into a severe costs of greater social isolation are public health costs. In depression, he turned to the arts—music, painting, and "perhaps the most discussed social science article of the especially poetry—for self-therapy, and these, his biogra- twentieth century" (Montanye, 2001, para. 1), and in a pher reported, were what "saved him" (Gopnik, 2008).
subsequent widely read book, Bowling Alone: The Col- Many studies suggest that enjoyable recreational ac- lapse and Revival of American Community, the political tivities, and the positive emotions that ensue, foster multi- scientist Robert Putnam (1995, 2000) focused on the im- ple psychological and physical benefits (G. Gordon & portance of social capital. Social capital is the sum benefit Esbjorn-Hargens, 2007; Ho et al., 2003; Lester & Russell, of the community connections and networks that link peo- 2008). However, some studies of recreation include and ple and foster, for example, beneficial social engagement, conflate additional healthy lifestyle factors such as exer- support, trust, and reciprocity (Bhandari & Yasunobu, cise, relaxation, and time in nature, and there are few 2009). Social capital seems positively and partly causally clinical guidelines. Mental health professionals will there- related to a wide range of social health measures—such as fore need to use their clinical skills to assess and support reduced poverty, crime, and drug abuse—as well as in- individual patients' interests. "The bottom line message is creased physical and mental health in individuals. Yet that we should work to cultivate positive emotions in considerable evidence suggests that social capital in the ourselves and in those around us not just as end states in United States and other societies may have declined sig- themselves, but also as a means of achieving psychological nificantly in recent decades (Putnam, 1995, 2000).
growth and improved psychological and physical health In short, relationships are of paramount importance to over time" (Fredrickson, 2002, p. 120).
individual and collective well-being, yet the number and Relaxation and Stress Management
intimacy of relationships seem to be declining. Moreover,"the great majority of individuals seeking therapy have Chronic stressors can exact a major toll across multiple fundamental problems in their relationships" (Yalom, organ systems and levels. This toll extends from psycho- 2002, p. 47). Clients' relationships are a major focus of, for logical to physiological to chemical (e.g., oxidative stress) example, interpersonal and some psychodynamic psycho- to genomic expression (hence the new field of psychosocial therapies (Shedler, 2010). Yet clients' interpersonal rela- genomics; Dusek et al., 2008). Even though stress is uni- tionships often receive insufficient attention in clinical and versal, few people are trained in managing it. In addition, training settings compared with intrapersonal and pharma- humans now face an array of novel stressors for which cological factors (Pilgrim, Rogers, & Bentall, 2009; Shed- there are no evolutionary or historical precedents. Many ler, 2010). Focusing on enhancing the number and quality people therefore respond unskillfully or even self-destruc- Month 2011 American Psychologist tively, aided and abetted by pervasive unhealthy influences Meditation can also be beneficial when combined with such as advertising, media role models, and novel psycho- other therapies. The best known combinations are dialec- active drugs (Buss, 2000). Yet many skillful strategies for tical behavior therapy (primarily used for borderline per- stress management are now available, ranging from life- sonality disorder), mindfulness-based stress reduction, and style changes to psychotherapy to self-management skills.
mindfulness-based cognitive therapy. A meta-analysis of Beneficial TLCs include almost all those discussed in this mindfulness-based therapies found large effect sizes for article— especially exercise, recreation, relationships, and anxiety and depressive symptoms of 0.95 and 0.97, respec- religious or spiritual involvement—and specific self-man- tively, and therapeutic gains were maintained at follow-up agement skills can both complement and foster these TLCs.
(Hofmann et al., 2010).
It is now clear that meditation, either alone or in combination with other therapies, can be beneficial for both Specific stress management skills include somatic, psycho- normal and multiple clinical populations. However, it is logical, and contemplative approaches. Somatic skills span less clear how different meditation practices compare or both ancient Oriental and contemporary Western tech- how meditation compares with other therapies and self- niques. The Chinese mindful movement practices of tai chi regulation strategies such as relaxation, feedback, and self- and qui gong are increasingly popular in the West, and hypnosis (Ospina et al., 2007; Walsh & Shapiro, 2006).
research studies suggest they are associated with both phys- Yoga may also be helpful for stress and mood disor- ical and psychological benefits (Kuramoto, 2006). A re- ders. However, studies on yoga are fewer, and reviews view of 15 randomized controlled trials of tai chi's effects have drawn cautious conclusions (da Silva, Ravindran, & on psychosocial well-being found significant benefits for Ravindran, 2009; Kirkwood, Rampes, Tuffrey, Richardson, the treatment of anxiety and depression but also noted the & Pilkington, 2005; Lipton, 2008; Pilkington, Kirkwood, mixed quality of the trials (Wang et al., 2009).
Rampes, & Richardson, 2005).
Western self-management skills include mental ap- In addition to its benefits for relaxation and stress proaches such as self-hypnosis and guided imagery (Trakh- management, meditation may also enhance measures of tenberg, 2008) as well as somatic approaches, especially psychological capacities, health, and maturity in both pa- muscle relaxation therapies that center on systematically tients and nonpatients (Walsh & Shapiro, 2006). Particu- tightening and relaxing major muscle groups. By doing larly important to health care professionals are findings that this, patients learn to identify and release muscle tension meditation can enhance valued caregiver qualities such as and eventually to self-regulate both muscle and psycholog- empathy, sensitivity, emotional stability, and psychological ical tensions. Muscle relaxation skills are widely used for maturity while reducing distress and burnout (Shapiro & the treatment of anxiety disorders, including panic and Carlson, 2009). On the cognitive side, studies suggest that generalized anxiety disorders, and meta-analyses reveal meditation can enhance some measures of cognition and medium to large effect sizes (Manzoni, Pagnini, Castel- may reduce age-related cognitive losses and corresponding nuovo, & Molinari, 2008).
brain shrinkage (Pagnoni & Cekic, 2007; Xiong & Do- Contemplative skills such as meditation and yoga are raiswamy, 2009). The universality of stress, as well as the now practiced by millions of people in the United States multiple benefits of both lifestyle changes and self-regula- and by hundreds of millions worldwide (Walsh, 2011).
tion skills for managing stress, suggests that these TLCs Concomitantly, an explosion of meditation research has and self-regulation skills deserve to be central components demonstrated a wider array of effects—psychological, ther- of health professionals' training, personal and professional apeutic, neural, physiological, biochemical, and chromo- practice, and public outreach.
somal—than are associated with any other psychotherapy Religious and Spiritual Involvement
(Walsh, 2011; Walsh & Shapiro, 2006).
Considerable research suggests that meditation can Religious and spiritual concerns are vitally important to ameliorate a wide array of (especially stress-related) psy- most people and most patients. Some 90% of the world's chological and psychosomatic disorders in both adults and population engages in religious or spiritual practices; these children (Arias, Steinberg, Banga, & Trestman, 2006; practices are a major means of coping with stress and Black, Milam, & Sussman, 2009; Chiesa, 2009; Dusek et illness; and most patients say that they would welcome al., 2008). Multiple studies, including meta-analyses, show their health professionals' inquiring about religious issues that meditation can reduce stress measures in both clinical (Koenig, 2002). Yet few health professionals do. This lack and normal populations (Chiesa & Serretti, 2009; Hof- of attention may be unfortunate given the prevalence and mann, Sawyer, Witt, & Oh, 2010). Partially responsive importance of religious and spiritual practices, their many psychosomatic disorders include, for example, cardiovas- influences on lifestyle and health, their impact on therapeu- cular hypertension and hypercholesterolemia, hormonal tic relationships and effectiveness, and the deep existential disorders such as primary dysmenorrhea and Type 2 dia- issues they open (J. W. Fowler, 1995; Koenig, 2009).
betes, asthma, and chronic pain (Anderson, Liu, & Kryscio, Considerable research suggests a complex but usually 2008; Shapiro & Carlson, 2009). Responsive psychological beneficial relationship between religious involvement and difficulties include, among others, insomnia, anxiety, de- mental health. The most massive review to date found pressive, eating, and borderline personality disorders (Di- statistically significant positive associations in 476 of 724 donna, 2009; Shapiro & Carlson, 2009).
quantitative studies (Koenig, McCullough, & Larson, Month 2011 American Psychologist 2001). In general, religious or spiritual involvement is most that view religion as, for example, always regressive or likely to be beneficial when it centers on themes such as always transcendental invariably overlook this develop- love and forgiveness and is likely to be less helpful or even mental perspective. Examples of reductionistic interpreta- harmful to mental health when themes of punishment and tions that view religion as necessarily regressive or patho- guilt predominate.
logical include the writings of the so called "neoatheists," Benefits span an array of health measures. Mental such as the recent extremely popular books The God De- health benefits include enhanced psychological, relational, lusion (Dawkins, 2006), The End of Faith (Harris, 2005), and marital well-being, as well as reduced rates of disor- and God Is Not Great (Hitchens, 2007), all of which are ders such as anxiety, depression, substance abuse, and ignorant of developmental research. Unfortunately, the suicide. For physical health, religious involvement seems widespread failure to recognize developmental differenc- beneficially related to both specific disorders such as hy- es—in faith, morality, values, ego, worldview, and more— pertension and to nonspecific mortality rates (Koenig et al., and their far-reaching implications for religion and multiple 2001). Strikingly, those who attend religious services at other areas of life seems a significant factor underlying least weekly tend to live approximately seven years longer many contemporary cultural conflicts (Walsh, 2009; Wil- than those who do not, even when factors such as baseline health and health behaviors are statistically controlled Of course, religious behavior can sometimes be re- (Koenig et al., 2001). Important mediating and contributory gressive or pathological. However, religious behavior can factors likely include service to others and especially social also both express and foster healthy, mature, and even support. Contemplative practices such as meditation offer exceptionally mature development. In fact, a classic goal of further psychological, somatic, and spiritual benefits (Di- spiritual practices such as meditation is to foster postcon- donna, 2009; Shapiro & Carlson, 2009; Walsh & Shapiro, ventional development through, for example, bhavana (mental cultivation) in Buddhism and lien-hsin (refining themind) in Taoism (Walsh & Shapiro, 2006). Contemporary Religion, Spirituality, and Psychological
research and meta-analysis are supportive, because medi- tators tend to score higher on measures of ego, moral, and It is important for mental health professionals to recognize cognitive development as well as self-actualization, coping that there are multiple levels of religious development.
skills and defenses, and states and stages of consciousness These levels range from preconventional to conventional to (Alexander & Langer, 1990; Alexander, Rainforth, & postconventional (or from prepersonal to personal to Gelderloos, 1991). Ideally, religious and spiritual traditions transpersonal) and are associated with extremely different offer both legitimacy (support for people's current level of kinds of religious faith, practice, behavior, and institutions psychological and faith development) as well as authentic- (J. W. Fowler, 1995; Wilber, 2005, 2006).
ity (support for maturation beyond current levels) (Wilber, For example, consider the developmental stages of 2005). Given the significance of religious and spiritual religious faith. At the preconventional level, mythic-literal involvement, it seems important for therapists to be famil- faith involves an unreflective, literal acceptance of cultur- iar with developmental and other key issues and, where ally provided beliefs. At the synthetic-conventional level, appropriate, to inquire about and support healthy involve- people begin to create their own individual, but still largely ment in this domain.
unreflective, synthesis of diverse conventional beliefs. At Contribution and Service
later postconventional stages, exemplified by conjunctiveand universalizing faith, individuals critically reflect on From ancient times, service and contribution to others have conventional assumptions, open themselves to multiple been regarded as virtues that can benefit both giver and perspectives, confront paradoxes, and extend their care and receiver (Walsh, 1999). The world's major spiritual tradi- concern to all peoples (J. W. Fowler, 1995; Wilber, 2006).
tions emphasize that, when viewed correctly, service is not When developmental differences go unrecognized, necessarily a sacrifice but rather can foster qualities that problems ensue. For example, the views of one level are serve the giver—such as happiness, mental health, and taken as normative, and those at this level tend to assume spiritual maturity. Altruism is said to reduce unhealthy that people at other levels are mistaken, misguided, malev- mental qualities such as greed, jealousy, and egocentricity olent, or disturbed (Wilber, 2005). Many contemporary while enhancing healthy qualities such as love, joy, and religious and cultural conflicts appear to reflect these kinds generosity (Hopkins, 2001; Walsh, 1999). The benefits of of cross-level misunderstandings (Walsh, 2009).
service are also said to extend to healing, such that healing This developmental perspective brings new clarity to oneself and others can be intimately linked. Multiple myths many religious and spiritual issues. For example, it makes and healing traditions describe wounded healers, people clear that religions are not only culturally diverse but also who by virtue of their own illness learn to heal others and developmentally diverse, and that mental health profes- may thereby be healed themselves.
sionals need to be sensitive to both kinds of diversity.
In our own time, both theory and research point to Religion can be an expression of immaturity, conventional correlations between altruism and measures of psycholog- maturity, and postconventional maturity, and of corre- ical and physical health. Multiple studies, including those sponding motives and concerns ranging from egocentric to that control for prior health factors, suggest that people ethnocentric to worldcentric (Wilber, 2006). Interpretations who volunteer more are psychologically happier and Month 2011 American Psychologist healthier, are physically healthier, and may even live longer have long been considered central elements of a life well (Borgonovi, 2009; Grimm, Spring, & Dietz, 2007; Post, lived. Now they can also be considered central elements of 2007). The so-called "paradox of happiness" is that spend- a healthy life.
ing one's time and resources on others can make onehappier (Walsh, 1999).
Altruists of all ages may experience a "helpers' high" A culture's technology has far-reaching effects on people's (Post, Underwood, Schloss, & Hulbert, 2002). Even re- psychology and lifestyles (Wilber, 2000), and modern tech- quired community service for adolescents seems to effect nology is now affecting our psychology, biology, society, long-term positive psychological changes, and even man- and lifestyles in ways we are only beginning to compre- dated monetary donations can make college students hap- hend. Moreover, technological innovations and their life- pier than spending the money on themselves (Dunn, Aknin, style effects are changing "more quickly than we know & Norton, 2008). Erik Erikson (1959) famously suggested how to change ourselves" (Putnam, 2000, p. 402). Many of that "generativity" (care and concern for others, and espe- the resultant costs are doubtless as yet unrecognized, and cially for future generations) may be a hallmark of suc- this raises a disconcerting question: Could some of our cessful maturation. Moreover, altruism has a positive social patients be "canaries in the coal mine," warning us of ways contagion or multiplier effect. For example, cooperative of life that may exact a toll on us all? This is a question that behaviors cascade through social networks to induce fur- health professionals will need to confront increasingly as ther cooperation in others (J. H. Fowler & Christakis, technological, environmental, and lifestyle changes accel- 2010), and at the community level, service is a key con- tributor to social capital (Putnam, 2000).
In summary, considerable research shows positive re- Interactions Among Therapeutic Lifestyle
lationships between altruistic behavior and multiple mea- sures of psychological, physical, and social well-being.
However, there are important qualifiers. Major exceptions Fortunately, individual TLCs appear to counter many med- include the caretaker burnout experienced by overwhelmed ical and psychological complications of contemporary family members caring for a demented spouse or parent.
pathogenic lifestyles. This raises a hopeful possibility: Furthermore, the kind of motivation powering the prosocial Might multiple TLCs be even more effective? There is behavior affects outcome. Whereas service motivated by evidence for this possibility in both animal studies and pleasure in helping is associated with multiple positive clinical medicine. For example, physical activity increases measures (such as positive affect, self-esteem, self-actual- neuronogenesis in the rat hippocampus. However, the ef- ization, and life satisfaction), this association may not hold fect is maximal only when the animals are exposed to a rich when service is driven by a sense of internal pressure, duty, social environment rather than living in isolation (Strana- and obligation (Gebauer, Riketta, Broemer, & Mai, 2008).
han, Khalil, & Gould, 2006). Similarly, in his program to Psychotherapists repeatedly rediscover the healing po- reverse coronary arteriosclerosis, Dean Ornish employed tentials of altruistic behavior for both their patients and four TLCs— exercise, vegetarian diet, relaxation and stress themselves. Alfred Adler emphasized the benefits of "so- management, and social support. Each proved beneficial, cial interest," and helping other group members contributes and the effects were additive (Pischke et al., 2008). Might to the effectiveness of group therapy and support groups this also be true for psychological disorders? Quite possi- such as Alcoholics Anonymous (Duncan et al., 2009).
bly, but as yet we have no clear answer.
Likewise, therapists often report that helping their patients Difficulties of Implementing Therapeutic
can enhance their own well-being (Yalom, 2002). Wisely perceived, altruism is not self-sacrifice but rather enlight-ened self-interest (Walsh, 1999). As the Dalai Lama put it, Given the many advantages of TLCs, why have mental "If you're going to be selfish, be wisely selfish—which health professionals been so slow to adopt them? The means to love and serve others, since love and service to reasons involve patients, therapists, and society. Effective others bring rewards to oneself that otherwise would be public health programs will therefore need to address all of unachievable" (quoted in Hopkins, 2001, p. 150).
These benefits of altruism hold major implications for For patients, TLCs can require considerable and sus- our understanding of health, lifestyle, and therapy. On the tained effort, and many patients feel unable or unwilling to basis of their research findings, Brown, Nesse, Vinokur, tackle them. Patients often have little social support, little and Smith (2003) wrote an article titled "Providing Social understanding of causal lifestyle factors, and a passive Support May Be More Beneficial Than Receiving It" and expectation that healing comes from an outside authority or concluded that interventions "designed to help people feel a pill (Duncan et al., 2009). Societally, whole industries are supported may need to be redesigned so that the emphasis geared toward encouraging unhealthy choices. Patients is on what people do to help others" (p. 326). Other contend with a daily barrage of psychologically sophisti- researchers quipped, "If giving weren't free, pharmaceuti- cated advertisements encouraging them, for example, to cal companies could herald the discoveries of a stupendous consume alcohol, nicotine, and fast food in the never- new drug called ‘Give Back'—instead of ‘Prozac'" (Post & ending search for what the food industry calls the "bliss Niemark, 2007, p. 7). Contribution and service to others point" of "eatertainment" through "hypereating" (Kessler, Month 2011 American Psychologist 2009). Unfortunately, one can never get enough of what of contemporary lifestyles, such interventions may be es- one does not really want, but one can certainly ruin one's sential. In the 21st century, therapeutic lifestyles may need health and life trying (Walsh, 1999).
to be a central focus of mental, medical, and public health.
Therapists also face challenges. The first is simply to become familiar with the large literature on TLCs. The second is a professional bias toward pharmacological and Alexander, C. N., & Langer, E. (1990). Higher stages of human develop- formal psychotherapeutic interventions. In addition, foster- ment: Perspectives on adult growth. New York, NY: Oxford University ing patients' TLCs can be time intensive, can demand considerable therapeutic skill, and is not well reimbursed.
Alexander, C. N., Rainforth, M. V., & Gelderloos, P. (1991). Transcen- Therapists may also harbor negative expectations (not dental meditation, self-actualization, and psychological health: A con- without some justification) that patients will not maintain ceptual overview and statistical meta-analysis. Journal of Social Be-havior and Personality, 6, 189 –247.
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