By Jessica Jones, MD
Many people, mental health professionals and patients alike, are curious about the growing movement of lifestyle interventions promoting brain wellness. There is growing scientific data on how behaviors like mediation, exercise, nutrition, and even time spent outdoors benefit mental health and increase resilience to stressors. The traditional interventions of psychiatric medication and psychotherapy remain essential for individuals struggling with severe psychiatric conditions, however questions about how to optimize treatment outcomes to prevent subsequent morbidity abound. Whether this is a reaction to disillusionment with big pharma or part of the bigger movement toward wellness, it seems like common sense that improving our daily habits could impact our long-term mental health, but these lifestyle changes prove difficult to put into practice for most. In my experience, shifting the therapeutic focus from finding the ‘right medication’ to finding a healthy mixture of lifestyle interventions, psychopharmacology, and psychotherapy has been key to improved quality of life and sustained recovery in the face of difficulties in many of the patients in my practice. The way to move toward a practice addressing lifestyle changes involves not only the ‘what’ of behaviors to change but the ‘how’ of making changes to promote wellness. This leads to the question: What are the best ways to start a new habit and maintain it? If we do decide to address lifestyle changes with patients, what are some helpful resources for education on evidence-based interventions to improve mental health?
To start any new behavior, it takes intention, energy, motivation, reinforcement, and a way to out-smart the barriers standing in the way of maintaining the new behavior. Individuals struggling with depression, for example, find that there is a scarcity of energy for even self-care, let alone new behaviors like meditation, taking medication, attending therapy, or taking a walk outdoors. Here are a few quick tips that have been useful in promoting behavior change:
- Helping the patient identify the reasons they would like to start a new behavior, like taking a daily walk outside, is much more effective than telling them all the reasons it is good for them. I often give a menu of evidence-based recommendations for lifestyle changes to address their concerns and ask which one appeals to the patient most, or which one they think would be easiest to incorporate into their daily lives. Seeing progress on self-selected goals is a strong motivator to keep going.
- Identify the smallest first step toward the new goal, something they can do immediately. If possible, we do that step together in the office. If not possible, we specifically plan for the soonest possible time they can do it. For example, if it is ‘taking a walk’, we will plan the time, place, gear needed, and a brief check-in via message once they have completed the task. Again, getting the momentum rolling for a new behavior is difficult, so exaggerating these first steps is often critical in helping someone get started. Other tricks that are useful are visual cues, i.e. a note on the bathroom mirror, placing the pillbox beside the toothbrush, taking walking shoes and clothes to work and going straight to the park afterward. Think ‘nudge’ theory, positive reinforcement and indirect suggestions equals effective behavior change.
- Use positive reinforcement. I am always surprised at how rarely adults use this for themselves to maintain a new behavior. It turns out it works time after time. The secret is to find something really rewarding to that individual. The rewards we often overlook include: positive social interaction, improvement in social status, unscheduled free time, and a sense of achievement. While tasty treats, or a new gadget are nice, they are not all we have in our quiver of goodies to help keep a new behavior going. Tracking behavior daily on a chart, app, or smart watch with a social media function is known to regulate the behavior in the way the individual intends. Programs that provide built-in social incentives are very useful in changing behavior.
- Plan for barriers. This is where your creativity as a clinician comes into play. There are as many barriers to starting a new behavior as there are people who want to change their behavior, probably even more. Taking time to do a little speculation with the patient about what might get in the way of starting the new behavior is helpful. Make a plan for how to deal with that problem. It models resiliency to the patient and normalizes the struggle of overcoming barriers to reach a goal. One underlying theme to many barriers is emotional decision-making. Essentially, it’s ‘I don’t feel like it after… (insert work, in the morning, today, ever, etc.). Discussing this barrier ahead of time is often necessary. Placing the behavior on the calendar like an appointment can help reserve time and serve as a reminder. Planning meals, exercise dates, trips to the mountains for the week ahead during times of lower stress, such as on the weekend, is extremely useful. Actually writing the plan down and having it visible can be helpful to stay on track and reduce the energy it takes to get started. Decision fatigue occurs after a day of making choices and shifting our attention among many things, making it difficult, and irritating, to make another tough decision. This is not the time to try to decide about whether to have salmon or a hamburger for dinner. Shift that decision to Sunday after you have had a nice meal, some time to relax, and can more clearly think about your goals.
- Check-in on progress. Have the patient send a mid-month message through the EMR portal. As a clinician, this allows you to cheerlead progress, trouble-shoot barriers, and help the patient refocus on the goal in real-time.
Here are a few helpful resources for incorporating healthy lifestyle changes for improved mental health. These are resources I often provide to patients depending on their goals.
Apps- for guided meditation
Headspace (Lite version is free)
The Nature Fix: Why Nature a Makes Use Happier, Healthier and More Creative by Florence Williams. A well-written book incorporating the latest research in the benefits of time spent in natural settings and exercise. It turns out our own backyards, not to mention the abundant parks and outdoor recreational opportunities in our community are huge benefits for our mental wellness.
Eat Complete: The 21 Nutrients that Fuel Brainpower, Boost Weight Loss, and Transform Your Health by Drew Ramsey, MD. He is a psychiatrist at Columbia University and has written several books about improving diet through whole foods and improving the microbiome of the gut. The information is straightforward, easy to incorporate into your life, and presented with a focus on wellness. His nutrition mantra, ‘Seafood, greens, nuts and beans…and a little dark chocolate’, is a good start to a grocery shopping list.
There is also a nice interview on the podcast, The Splendid Table, for those who prefer an audio format.
The Confidence Gap: A guide to Overcoming Fear and Self-Doubt by Russ Harris. This is a great self-help book for individuals who struggle with anxiety as a barrier to behavior change. It is based on the psychotherapy Acceptance and Commitment Therapy, which is an evidence-based psychotherapy for anxiety disorders and depression. It incorporates many helpful exercises to teach a new way of relating to strong emotions. This would be a useful tool for individuals who are stuck due to anxiety.
Jessica Jones, MD is a Private Practice Psychiatrist with Utah Center for Evidence Based Treatment. She is also Adjunct Faculty with the Dept. of Psychiatry at the University of Utah.