Moving from Illness to Wellness

By Jessica Jones, MD

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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?

Habit-Forming:

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

Resources:

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.

Meditation:

Apps- for guided meditation
Headspace (Lite version is free)

Smiling Mind 

Insight Timer

Nature Melody 

 

Podcasts

Meditation Oasis 

Mindfulness + with Thomas McConkie

 

Books

Full Catastrophe Living by Jon Kabat-Zinn, PhD

10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-Help That Actually Works–A True Story by Dan Harris

Getting Outdoors/Exercise:

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.

Nutrition:

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.

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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.

 

One in Five

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By Vanessa Galli, MD

Nearly one in five women have reported experiencing rape in their lifetime according to the most recent data from the CDC. Statistics never mean as much to the reader as an “n of one” or a personal testimony. I myself am the one in five, a survivor of rape. That is not the point of this article, but rather serves as a context for a larger conversation.

I bring this all up at the beginning of this article because it shouldn’t be any different than talking about any other part of one’s life story. The shame and the embarrassment that these events are shrouded in stops us from having open conversations and prevents survivors from seeking the help that they need. I also bring this up to challenge your stereotypes about rape trauma survivors and for any of you reading this who share my experience to remind you that you are not alone in this journey. One in five means that many of you reading this unfortunately share this part of my life’s story.

Sexual assault can come in so many forms, both big and small. I have always been aware of gender biases in conversation, although have become increasingly aware of these throughout medical training. Each time I was called “Sweetie”, “Honey”, and “Angel” and told that I “looked like a Barbie Doll” by patients, it became harder to just shake it off and walk away. I attempted gentle correction, changing the subject and removing myself from the conversation. I never found a “good” solution and was left feeling guilty on some level. I found myself asking the question, “What did I do to bring this on?” I was experiencing some form of survivor’s guilt.

I also began see how often we do this to one another in the work environment. I began to notice that my female colleagues are frequently addressed collectively as “ladies” or automatically by their first name in conversation, while their male colleague sitting next to them may be addressed in the same breath as doctor. In the hospital setting, I have overheard staff complementing male providers for their “bluntness” and female providers with a similar communication style accused of being “harsh and unapproachable.” We live in a world of micro-assaults that are committed innocently in the work place every day.

So what exactly do we do about this? I do not believe in being overlying politically correct as that doesn’t further the conversation and leads only to frustration and tip-toeing around the true issues at hand. I believe in being direct and open in communication, a style that was born from my Northeast roots. So on that note, I challenge each person reading this to question your own preconceived notions and stereotypes. We are in a line of work that relies on solid skills in pattern recognition and judgement, although sometimes we need to leave that judgement at the door. We need to have open conversations with each other. We need to feel comfortable and safe correcting one another, whether it be a patient or a co-worker. Only then, will we create a work environment and a patient care environment that is safe for everyone.

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 Vanessa Galli, MD is a Chief Resident in the Family Medicine Residency Program in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

 

Choosing Gratitude

By Kara Frame, MD

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I don’t remember the exact lecture or rotation, but somewhere along the course of my medical school education, I was taught this powerful lesson: a person is capable of changing how she thinks.  Of course, people have natural tendencies- leaning more positive or tending toward a more pessimistic outlook- but to some degree these preferences are pliable rather than fixed.

 

In a very rudimentary way, it can be explained like this: our brains are facile, constantly remodeling themselves.  And, if a thought becomes repetitive, it reinforces the nerve pathway that it triggers, essentially making the pathway stronger. The reverse can also be true, if we de-emphasize a certain pathway (thought process) it may become less prominent. This lesson resonated with me and the concept seems to resurface in my conscious at different intervals in my life.

 

As a family doctor, the idea has helped me offer hope to patients, many of whom, unfortunately, struggle with depression and anxiety.  Of course, I would never mean to suggest to them or to you that their disease can just be willed away, that simply reframing their thinking will make all of their problems disappear.  That way of thinking suggests the disease is completely within their control, something they might have caused or are responsible for, which is grossly false and is partly responsible for the stigma they often feel when it comes to mental health conditions. It minimizes their experiences.  However, when I talk about the multi-pronged treatment that I often recommend for depression or anxiety, it typically includes medication, good therapy, and lifestyle interventions.  The last part can be overwhelming but it can also be empowering.  When you are battling depression and/or anxiety, so much feels out of control.  You might feel at times as if you are “going crazy” or losing your mind.  It often comes with a sense of hopelessness.  So, the idea that there may be things within your control can be uplifting.

 

Eating well, being physically active, being rested, generally taking care of ourselves: these are the pillars of health that can be difficult to maintain even when we are not depressed, so trying to do this under the weight of depression can become impossible.  Therefore, I encourage my patients to start very small.  To choose one thing to focus on first and then we build over time from there.  Still, just wanting to exercise more or eat “better” doesn’t often get the desired results, so we often have to back up a few steps.

 

No one can make a change until she understands what is stopping her in the first place.  And, for many of us, that something that is in the way is often our own thinking.  “I am so out of shape, what’s the point?” “I can’t even walk to the mailbox-there’s no way I can run.” “I have already eaten half the bag, what difference does it make if I eat the whole thing now?”  These are all paraphrased examples of the negative self-talk, I have heard from patients.  When they start to think about change, some version of these negative thoughts will run through their heads. And, once these negative thoughts are recognized, the work of re-framing them can begin.  If we recognize the repetitive thinking as it begins, we can then stop it and shift to something different, replacing the negative with more positive and actionable thoughts.

 

As for us doctors, we are not above the negativity.  In fact, we are often more susceptible. It is generally accepted that doctors have a higher rate of burnout than the general public, and we certainly are at risk for depression.  People talk about the jadedness that often envelops physicians somewhere along their training- people who began a profession with total optimism and a desire to help too often becoming filled with negativity and, sometimes, contempt.  I have seen this in residents, young doctors going through the gauntlet that is residency.  There are times when it can become overwhelming and even the most positive can begin to falter.  And, I have seen this in seasoned physicians with many years of practice under their belts.

 

For my own part, I have been pretty fortunate.  I have been lucky to train, both in medical school and in residency, at places that were very supportive.  And now, I work in a program that places a very high value on personal wellness.  And yet, there have been times when I found myself slipping into negativity, too.  Something I subconsciously considered myself to be above happening to me, just as I had witnessed in other friends, colleagues, and learners.  I have always considered myself to be a positive person, so don’t like it when this new pessimism starts slithering in.  I try to practice what I preach and make an effort to change.  By consciously focusing on the countless things I am grateful for, at least once each day, there is less time for the negative chatter.  When I start this practice, sometimes it is hard to think of much, but as I become more practiced, numerous things pop into my head each day.  By choosing gratitude I also shift back toward optimism.
As I am writing this, I recognize that I am vastly oversimplifying a very complicated process, a process that often has many starts and stops, times of progression and regression.  Yet, in a time where there is a lot of uncertainty, when many feel lost and as if there is nothing in their control, I find it comforting to be reminded that we can do something pretty big: we have the power to change the way we think.

Frame

Kara Frame, MD is an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.