The Art of Manliness - The Exercise Prescription for Depression and Anxiety

00:00:00.000 Brett McKay here and welcome to another edition of the Art of Manliness podcast.

00:00:10.500 Now, if you went to the doctor about treating your depression or anxiety, you might expect

00:00:13.960 to be written a prescription for Zoloft or Xanax.

00:00:16.420 But if you went to see Dr. Jasper Smits, he might write you a different kind of prescription,

00:00:20.100 one that instructed you to take a jog around the block.

00:00:22.740 Dr. Smits is a professor and clinical psychologist, as well as the co-author of the book, Exercise

00:00:26.940 for Mood and Anxiety, Strategies for Overcoming Depression and Enhancing Well-Being.

00:00:31.020 Today on the show, we talk about why he likes to use exercise as an option for patients

00:00:34.480 who struggle with mood disorders, anxiety, and even general stress and anger, but don't

00:00:38.120 want to do talk therapy or take a medication.

00:00:40.460 We discuss how exercise has been found to be as effective for depression and anxiety as

00:00:43.800 medication and, of course, has a much better side effect profile, why it works, and whether

00:00:47.900 a particular type of exercise is better for particular disorders.

00:00:50.880 We then spend the rest of the conversation digging into the Catch-22 that surrounds depression

00:00:54.900 and exercise.

00:00:55.560 If exercise is good for depression, but when you're depressed, you don't feel like exercising,

00:00:59.680 how do you find the motivation to get going with it?

00:01:01.860 We discuss strategies for starting and sticking with exercise that can help not only those

00:01:05.340 who struggle with mood disorders and anxiety, but anyone who's looking to make physical activity

00:01:09.120 a habit.

00:01:09.920 After the show's over, check out our show notes at aom.is slash exercise for mood.

00:01:13.820 Jasper Smits, welcome to the show.

00:01:26.340 Thank you.

00:01:27.640 Thanks for having me.

00:01:28.940 So you've got a book called Exercise for Mood and Anxiety, Proven Strategies for Overcoming

00:01:33.700 Depression and Enhancing Well-Being.

00:01:35.740 And you're a psychologist, and you've taken a look at exercise, but you're taking a look

00:01:40.060 at exercise, the mental health benefits of exercise.

00:01:42.420 I think most times when you see research about the benefits of exercise, it's always on the

00:01:46.340 physiological, how it helps your heart, your muscles.

00:01:50.000 What led you down the path to exploring the psychological benefits of exercise?

00:01:54.720 Yeah, you know, I've been interested in getting good treatment to people with mood and anxiety

00:02:03.020 problems.

00:02:04.060 And as a psychologist, as you just mentioned, I've been a big fan of psychotherapy, trained

00:02:09.920 in cognitive behavior therapy or CBT.

00:02:12.740 I like the evidence for that treatment, and I'm heavily involved in the implementation of

00:02:18.540 it locally, but also through trainings and so forth.

00:02:21.540 And I also really appreciate medications.

00:02:25.080 I think they have an important role in the treatment of mental health problems, anxiety

00:02:29.560 and mood disorders.

00:02:30.680 And when you take a look at how these two fare, they do really well.

00:02:35.200 There's a good evidence base for CBT.

00:02:37.200 It produces strong effects.

00:02:39.640 Same is true for medications.

00:02:41.260 But as you could probably expect, a lot of people also don't do very well with CBT or don't

00:02:46.420 do very well with medications.

00:02:48.760 And even if they could, let's say they have the right disposition to respond well to these

00:02:54.540 interventions, they may not have access to it, to CBT, like I can't find a good provider,

00:03:00.300 or they may not care for it.

00:03:02.120 Some people just don't like talk therapy or they don't like taking medications.

00:03:06.420 And I think it's up to us, people who research these kind of interventions or invested in

00:03:12.960 getting good treatments out to people, is to increase the offering.

00:03:16.300 I'm really excited to see the expansion of digital health products.

00:03:19.920 I think that's going to help a great deal.

00:03:22.020 And when I think about what's available and what should be part of the offering, I think

00:03:26.440 exercise should be part of that.

00:03:28.600 Exercise has strong effects for mood and anxiety disorders and related problems.

00:03:33.160 And I also think that exercise fits in well for people who come to see us.

00:03:40.160 Most people, you know, they come to see us obviously for symptom relief, and that's where

00:03:44.260 medications and psychotherapy can really affect us.

00:03:47.600 But most people actually come not just for that, but they just want a better life.

00:03:51.620 They want to increase their well-being.

00:03:54.240 And I think exercise is part of that picture for most people.

00:03:57.840 If you ask people who are physically active, you know, what does it do for you?

00:04:02.300 People will say, it improves my well-being.

00:04:04.340 It makes me feel physically better.

00:04:07.220 And, you know, the direction from physical health to mental health is there.

00:04:11.980 If you feel physically better, you often feel mentally better as well.

00:04:16.220 And it's been rewarding to be involved in sort of pushing this out as one of many available

00:04:22.080 strategies for people who struggle with mood and anxiety problems.

00:04:24.780 All right.

00:04:25.580 So the goal is to increase the offerings or the options for people who have some mental

00:04:30.100 health issue.

00:04:31.260 So let's talk about exercise.

00:04:32.500 In the book, you highlight a lot of research that talks about the mental health benefits

00:04:37.280 of exercise.

00:04:38.580 So like, for example, what do we know about the benefits of exercise for mitigating or managing

00:04:45.140 depression?

00:04:46.740 For depression, the evidence base is actually really pretty good.

00:04:49.660 You know, the gold standard for interventions is to do a randomized controlled trial.

00:04:53.540 And that's how we study drugs.

00:04:55.920 That's how we study psychological treatments.

00:04:58.460 And when you look at those trials for exercise, they yield effects that are comparable to what

00:05:03.320 we see in drug therapies and psychotherapies.

00:05:05.980 So it's good.

00:05:07.660 It's not as strong as these to establish interventions, but mostly because there have been just fewer

00:05:14.700 studies.

00:05:15.820 So when you look at the size of the evidence base, it's less.

00:05:19.300 But when you look at the effects, it's about equally effective.

00:05:22.140 There have only been a handful of studies that have actually compared exercise to, let's

00:05:27.760 say, medications for psychotherapy.

00:05:29.620 They're few in number.

00:05:30.720 They're sort of small in size.

00:05:31.980 But when you look at those, exercise stacks up actually pretty well in terms of tolerability.

00:05:37.360 Dropout rates are about similar to those interventions.

00:05:40.100 And the effects are about comparable as well.

00:05:42.520 So that evidence base is what gives us the comfort of suggesting this as a prescription for

00:05:49.220 people with mild to moderate forms of depression.

00:05:52.420 And what about anxiety?

00:05:53.840 Is there any research about exercise and anxiety?

00:05:56.200 There is.

00:05:57.200 And often actually studied mostly in medical populations.

00:06:01.400 So anxiety among people who have a chronic illness and less so in the anxiety disorders,

00:06:06.840 let's say obsessive compulsive disorder, panic disorder, post-traumatic stress disorder.

00:06:11.160 Evidence has grown there, but much smaller in number.

00:06:14.020 But the findings that are out there to date also suggest that the effects are really pretty

00:06:18.580 good.

00:06:19.940 And to where I feel comfortable making a part of the offering and say, like, when I look

00:06:24.280 at these trials and I look at the effects, I think it shows that exercise does definitely

00:06:28.980 better than doing nothing.

00:06:31.400 And in many cases, also better than what is a reasonable control like stretching or something

00:06:36.400 else that is sort of a minimal intervention.

00:06:38.700 I know the research is limited, but has any research been done about particular types of

00:06:44.280 exercise being particularly useful for a specific type of mood disorder?

00:06:48.660 I mean, I guess the question, I mean, like, do you prescribe like, okay, if you're depressed,

00:06:52.360 do cardio, or if you're anxious, do yoga?

00:06:54.740 Is there anything like that?

00:06:55.500 Or is it basically just any type of exercise will give you benefits no matter your mood disorder?

00:07:03.240 Yeah, I think if we just stick with the evidence, and that's never a bad idea, right?

00:07:06.900 If we stick with the evidence, we'd say if you follow the public health guidelines for

00:07:11.320 exercise, which is like 75 minutes of vigorous or 150 minutes of moderate intensity exercise

00:07:18.420 a week, aerobic, with a combination of some strength training, put you in a good position

00:07:24.960 to see the effects over a few months.

00:07:28.440 And that's, I'm saying that because that's often the dose that's been studied in these large

00:07:33.160 randomized control trials.

00:07:34.420 So that's a safe bet.

00:07:36.740 But I think we're starting to see in some initial research here that an effective exercise

00:07:43.020 prescription for people with any mood or anxiety disorder, or whatever they present with, is

00:07:49.220 going to require that you really take into account their preferences in terms of what they would

00:07:53.020 like to do and what they think they can do, as well as the targets.

00:07:57.380 And let me speak a little bit more about the targets.

00:08:00.120 Targets I think about, let's say, let's take someone with a mood problem where you find

00:08:05.700 that isolation, for example, is a big factor in their depressed mood.

00:08:11.320 Then an exercise program that involves social activity, so a group like exercise or exercise

00:08:19.360 with a buddy, is likely going to be more effective in getting them their effects than if they are

00:08:26.720 exercising on their own.

00:08:29.040 Preferences, too.

00:08:30.020 Most people, particularly those who come to see us who are inactive, don't necessarily have

00:08:34.800 a positive experience with exercise or history with exercise, and they don't necessarily like

00:08:40.420 exercise.

00:08:40.940 Otherwise, often they will be doing it.

00:08:42.660 And so, exercise is often equated with hard work, running, running outside, running in

00:08:49.300 the heat, running in the cold.

00:08:51.080 And those are not the things that you want to start with, with someone who already is suffering

00:08:54.820 from depressed mood and who has a hard time engaging in values-based actions.

00:09:00.240 And so, much of the work up front is really about getting a good sense of what it is that

00:09:06.640 the person might be interested in doing and going over a list of different possible activities

00:09:12.560 that count as exercise.

00:09:15.020 And that's often where you start.

00:09:16.980 And so, for some people, that might be taking a yoga class.

00:09:20.380 Or for other people, that might be taking up swimming.

00:09:23.460 For others, it might be playing tennis.

00:09:25.820 Any kind of exercise that is often different from aerobic.

00:09:28.860 And that might be a really good starting point for people to start forming an exercise

00:09:33.660 habit and to also recognize that over time, that exercise habit might change.

00:09:40.300 So, as people get more comfortable with, let's say, yoga activity and more comfortable with

00:09:46.580 actually making that part of their weekly habit, Tuesday mornings is an hour that I reserve

00:09:51.480 for yoga, they may be more interested and willing and able to pick up or add another activity

00:09:57.420 that may be a bit more strenuous, like more strongly in aerobics.

00:10:01.760 So, they may go from an easy, so to speak, yoga to more of a power yoga, or they may find

00:10:08.080 another class that's available at the gym that they attend.

00:10:11.340 And so, I am a big believer in spending a good amount of time with people at the beginning

00:10:15.900 to get a sense of what they think they might like, list those activities, and then tie them

00:10:21.600 again to what the targets are for them.

00:10:24.220 And then start building that exercise program over time, making sure that you stay flexible,

00:10:28.760 that that program likely will change as people get more used to activity in general.

00:10:34.220 So, with a lot of mental health interventions, whether it's talk therapy or drugs, sometimes

00:10:38.200 it takes a while before you see the effect, particularly with cognitive behavioral therapy.

00:10:42.500 It's not something you, I mean, oftentimes you don't notice it right away.

00:10:45.340 Is it the same thing with exercise?

00:10:46.900 I mean, does the benefit take a while?

00:10:48.540 Or do you, once people start moving their body, do they notice a marked difference?

00:10:53.160 Yeah, I think it's one of the beauties of exercise, and particularly exercise for mental

00:10:59.820 health.

00:11:00.380 I mean, we often think about exercise for physical health, and let's say we think about

00:11:05.360 it for weight loss, as something that is going to take a while.

00:11:09.080 And so, the distance between starting the exercise or the activity and the desired outcome

00:11:14.700 is a long time.

00:11:16.660 And I think that's actually also true for stable reductions in depressed mood.

00:11:22.600 When you think about these large randomized controlled trials, they often go for three

00:11:26.440 months and then assess where people are in terms of their depressed mood for that particular

00:11:31.740 week and then the follow-up period.

00:11:33.980 But as I said, the beauty for exercise is that most people, even if they don't enjoy the

00:11:40.280 actual activity, and that is that during the activity, they report it being difficult and

00:11:46.180 challenging, they will report a nice reduction from how they felt in terms of stress or tension

00:11:53.600 or depressed mood before the activity relative to after the activity.

00:11:58.520 So, you get that immediate boost of like, hey, I did the exercise, that may have been really

00:12:03.120 difficult, but man, I feel much better now than I did at the beginning.

00:12:07.840 And we use that usually as the hook to get people interested and curious about making this part

00:12:15.160 of their regular habit, is pay attention to what exercise does for you that particular day.

00:12:21.780 I usually tie exercise prescription to what is relevant to a person for that particular day.

00:12:27.740 Let's say I take someone who gets really stressed by attending work meetings and they have a big

00:12:36.880 meeting on a Thursday.

00:12:38.760 I might say, hey, this meeting is a Thursday at noon.

00:12:41.900 Can we plan an exercise belt, let's say in the morning, so that you feel the effects of exercise

00:12:48.440 before you go into that meeting, fare better in that meeting in terms of feeling a bit more

00:12:54.280 stress resistant, a little less reactivity during that meeting, so that at the end of that day,

00:13:00.740 you look back, you can say, hey, this really worked for me.

00:13:04.420 Like today, even though it was difficult this morning when I woke up and I decided to do that

00:13:10.020 activity, it paid off for me immediately.

00:13:12.400 And that's a reason for me to continue to do it.

00:13:15.020 And then as people get into that habit of doing this more over time, they will start seeing those

00:13:20.980 more durable reductions in depressed mood or anxiety or whatever it is that they are seeking

00:13:26.820 help for.

00:13:27.940 Okay.

00:13:28.300 So yeah, that's an interesting point.

00:13:30.220 Exercise, as you said, when you're pitching this to a patient and saying, hey, this might give

00:13:35.520 you like immediate benefits in the short term, and it can be a nice supplement to what we're

00:13:39.800 doing with the talk therapy as well.

00:13:41.440 So I think I'm sure, imagine a lot of people when they're coming to you, they want a quick

00:13:45.720 fix.

00:13:46.160 They know that it's not going to be a quick fix.

00:13:47.720 They got to do some work, but exercise, hey, this can do maybe something a little bit

00:13:52.140 for you to keep you going.

00:13:54.200 I do think that's one of the appealing parts of the exercise prescription is that you can use

00:13:59.840 it in the short bout prescription.

00:14:02.600 One of the things that I do sometimes with my patients is just the 10 pushups.

00:14:07.660 People who sometimes experience intense activation of stress or frustration and don't really know what to do with that feeling and feel like all they can do is maybe act on

00:14:20.080 that feeling in a way that's ultimately going to be more harmful than good.

00:14:25.000 Then something like 10 pushups can be really helpful to allow people to sort of shift their

00:14:29.160 attention from that intensity to, again, back to where they want to be, which is to focus

00:14:34.780 on what's in front of them, whether that's their work or whatever they were doing at that

00:14:38.720 time.

00:14:39.640 So the short bout can be really helpful for getting people to see those quick reductions in whether

00:14:46.540 it's frustration, tensions, or sad mood that allows them to stay engaged in a way that

00:14:52.780 really works for them in the long term.

00:14:55.280 So we've talked about, okay, there are benefits.

00:14:58.580 The research says there are.

00:14:59.600 Do we know how exercise works in helping with mood disorders?

00:15:05.460 I think we have a lot of ideas of why it may work.

00:15:09.840 And, you know, as a psychologist, I've been mostly interested in sort of the behavioral psychological

00:15:15.780 mechanisms.

00:15:16.660 And one of the reasons why I actually started researching exercises, because I thought in

00:15:22.760 an intense form, and that is when you really get people to do aerobic exercise, and they

00:15:28.780 feel all kinds of bodily sensations like racing hard, sweating, breathing faster, it can actually

00:15:35.840 serve almost like something that we call exposure therapy, which is really effective with people

00:15:41.380 who have anxiety problems.

00:15:43.120 And that is, if you get people to do these quick bouts of exercise, they get to really

00:15:48.760 see that even though it could be uncomfortable to see your heart racing, or that you're breathing

00:15:53.960 faster, that you're sweating, it doesn't mean that it's going to lead to disastrous consequences.

00:15:59.760 People with anxiety sometimes are concerned that heart racing is going to lead to, let's

00:16:03.460 say, a heart attack, or that breathing faster is going to lead to suffocation.

00:16:08.080 So in that way, exercise can be a really effective way to deliver that kind of exposure therapy.

00:16:15.040 So we've thought, hey, maybe it's one of the mechanisms of exercise is what we call this

00:16:20.380 reduction in fear of fear or anxiety sensitivity, the sensitivity to anxiety and the related sensation

00:16:27.480 or building up people's what we call the stress tolerance, the ability to withstand the stress

00:16:34.520 and say like, hey, it's there, feeling it, I do have a tendency to want to push this away.

00:16:42.180 But because I'm exercising, and I have this experience, I know that I can actually stick

00:16:47.140 with it and persist over time.

00:16:50.100 And that is a powerful mechanism for many anxiety and related problems.

00:16:55.660 And so that may be what's happened at the psychological level.

00:17:00.180 And then I think also in the book, you highlight, you know, there's probably some endorphin stuff

00:17:02.940 going on, we all know about your body releases neurotransmitters when you exercise, and that

00:17:07.200 could help too.

00:17:09.040 For sure.

00:17:09.700 I mean, I think, does exercise affect the brain?

00:17:13.260 The answer is for sure.

00:17:15.180 And I think that question is particularly interesting for researchers who are obviously interested in

00:17:22.400 figuring out the mechanisms of action for any intervention.

00:17:25.500 The idea is that if we know how it works, maybe we can make it even better.

00:17:29.280 Or we can learn about new treatments if we figure out how exercise can improve mood and what are

00:17:34.780 the different brain regions that are involved.

00:17:37.440 Perhaps we can develop new drug treatments that act on these brain regions.

00:17:41.920 And so it can be informative from that perspective.

00:17:44.760 I also think it's helpful sometimes for patients and provider to know how it affects the brain,

00:17:52.040 because somehow knowing that it affects the brain makes the intervention for many more

00:17:57.900 legitimate, like it makes it a real intervention.

00:18:01.900 And I have been following that research.

00:18:03.860 It's not my expertise.

00:18:05.060 And my sense is that it is challenging to pinpoint where the action is.

00:18:13.260 And I think in part, because it's difficult to study, studying mechanisms of actions really

00:18:18.940 require, you know, lots of assessments, lots of subjects to really figure this out.

00:18:25.140 I also think it is challenging because exercise works for so many different things.

00:18:31.940 You know, it works great for mood and anxiety.

00:18:34.320 It also works for all kinds of physical health problems.

00:18:36.860 So most likely, exercise will have broad effects and also lots of different mechanisms at different

00:18:44.780 levels of analysis.

00:18:45.640 So it's an important puzzle.

00:18:47.840 I really like the work that's being done in that area.

00:18:50.540 But I do think it's going to take a while for us to really get some good insights as to

00:18:54.920 where the action really is.

00:18:56.640 But hopefully, we will see it in the years to come.

00:19:00.140 We're going to take a quick break for your word from our sponsors.

00:19:03.820 And now back to the show.

00:19:05.740 Okay, so your focus is, you know, it works.

00:19:08.320 There's research that suggests that it does work.

00:19:10.520 So your goal is, okay, what can I do to help my patients do this thing that I know that

00:19:14.860 know could help them?

00:19:16.040 But the catch-22 with a lot of mental health issues, particularly depression and anxiety,

00:19:21.180 is that you typically are not motivated to do anything.

00:19:24.500 So it's like, how do you get motivated to exercise, which a lot of people aren't motivated

00:19:29.180 to do anyways.

00:19:30.560 And so you spend a lot of time in the book walking through strategies to overcome this

00:19:34.640 obstacle.

00:19:35.900 So let's talk about this.

00:19:38.420 Let's talk about, first off, the obstacle of depression getting in the way of exercise.

00:19:42.360 Like, what are the cognitive distortions that can occur with depression or even anxiety

00:19:47.560 too, that gets in the way of people doing something that they know could help them?

00:19:55.000 Yeah, I think let's go through a few.

00:19:56.800 But the first is, this is not going to work for me.

00:19:59.460 Pessimistic outlook and fitting with that is this particular intervention doesn't work

00:20:04.760 with me.

00:20:05.200 And perhaps there's also some history of exercise that feels to the patient, confirms

00:20:10.940 that I've never liked exercise or I've never really gotten the benefit of exercise like

00:20:16.200 others have.

00:20:17.100 So that's then a challenge for the provider.

00:20:21.020 And I think it starts with first some education and just briefly outlining what the effects of

00:20:28.320 exercise can be, which I think is important for any kind of intervention.

00:20:31.420 But education alone is not going to do it.

00:20:33.860 So ultimately, you know, patients might appreciate knowing that it might work and it works for

00:20:40.320 others, but they might still leave with this sense like, well, if it works for others, that's

00:20:44.080 great, but it might not work for me.

00:20:45.820 I would have to see that for myself.

00:20:47.560 And I think that's where it comes to experiential learning.

00:20:50.640 So I usually set up basically an experiment with my patients and hope that I can get them

00:20:56.740 to be willing to try exercise for a short period of time, even like, let's say a week.

00:21:04.220 And the experiment is really to see if we manipulate exercise, so we get people to commit

00:21:10.180 to some sort of exercise for that week, if it actually does deliver or yield the kind of

00:21:16.660 effects that they will be interested in.

00:21:18.340 So now I'll go back to what I mentioned before, which is the targets.

00:21:21.060 So let's say I have someone with a depressed mood who also struggles with sleep, or one

00:21:26.640 of the powerful effects of exercise is improved sleep.

00:21:30.200 So I might ask that person to say, like, how about we track sleep for the next week and

00:21:36.920 just kind of a sleep rating in the morning, what was the quality of your sleep?

00:21:41.740 And what we can do is come up with what we think is reasonable exercise for you.

00:21:45.940 And I'm saying just for a week, right?

00:21:47.820 I'm not asking you to exercise for the rest of your life or even for two weeks.

00:21:52.360 For the next week, would you be willing on some of these days to engage in exercise and

00:21:58.140 then see what happens with your sleep on those days?

00:22:00.740 And we can just keep track of this, right?

00:22:02.700 We'll manage or we track your exercise or your physical activity.

00:22:06.600 We'll also track your sleep and then we can review those data together and we can decide

00:22:11.820 whether this is something that works for you.

00:22:14.280 And so that's the setup.

00:22:15.840 Most patients will be intrigued and they'll respond and say, like, well, I can probably

00:22:21.680 do anything for a week, but let's talk a little bit more about what exercise might look like.

00:22:26.720 And I think you have to go to preferences.

00:22:28.720 And you can't just send a person away and say, like, hey, why don't you go try this now?

00:22:34.180 You actually have to start talking about, well, what might that exercise week look like for

00:22:39.520 you?

00:22:39.800 So let's think about this.

00:22:40.980 Today's Tuesday.

00:22:43.160 I'll see you again next Tuesday.

00:22:44.620 What does your week look like?

00:22:47.200 And what can we do in terms of an activity?

00:22:49.980 Can we do something outside around you?

00:22:52.720 Is there a club near?

00:22:54.180 Is there a partner?

00:22:55.860 Is there a friend who can do something with you?

00:22:58.260 What kind of exercise history do you have?

00:23:01.140 Do you remember an activity that you sort of feel like you can maybe try for this week?

00:23:05.680 Is that walking?

00:23:06.400 Is that something else that might come to mind?

00:23:09.800 So it's a lot of sort of problem solving, troubleshooting, and brainstorming there in

00:23:15.740 the beginning to come up with a plan that is feasible.

00:23:19.960 The question I ask at the end is like, hey, we've now discussed this.

00:23:23.240 We have a week.

00:23:24.000 You've set on two of the days.

00:23:27.020 You're going to walk for 20 minutes with your friend.

00:23:30.360 You're going to do this on Thursday at 5 p.m.

00:23:33.500 You're also going to do this Sunday morning at 10 a.m.

00:23:37.200 We have the places where you're going to meet your friend.

00:23:40.420 We have the tracking system set up.

00:23:42.980 This is going to be effortful because it's going to be very different from what you've

00:23:46.620 done in the past and certainly what you did over the last few weeks.

00:23:49.620 How likely do you think it is that you actually will be able to do this?

00:23:54.640 And if a person says, you know, 70%, 80%, I'm happy.

00:23:59.600 I mean, that sounds pretty good.

00:24:01.340 And I think that's a good way to get this started.

00:24:04.300 If it's less than that, we have to go back maybe in that session or subsequent sessions

00:24:08.500 to figure out what parameters we need to change to get that to a higher likelihood.

00:24:13.280 And what's interesting is the way you describe that process.

00:24:15.120 You're not telling the patient to like, well, just get motivated from within, find that from

00:24:19.980 within yourself.

00:24:20.600 You actually created with the patient the motivation like that's outside of them.

00:24:25.300 Like you've set up a system.

00:24:26.480 There's like a person, there's a place, there's a time.

00:24:29.080 They just have to show up and do it.

00:24:30.500 It's nothing really is like, there's hardly any internal motivation going on.

00:24:35.420 I think that's right.

00:24:36.580 I think that if we just tell people, go do it, we will see something that we also see

00:24:43.060 in the literature, which is 40% of people report being inactive, even though they hear

00:24:48.760 from their physician, you should be physically active.

00:24:51.460 So just telling people to go do it, particularly with something that's effortful, like exercise,

00:24:55.760 and then particularly also when you already struggle with mood, it's just a non-starter.

00:25:01.860 That's not going to go anywhere.

00:25:03.160 So you're going to have to work with a person to shape their environment such that they can

00:25:10.120 actually be motivated to do this so that exercise can sort of go up to the hierarchy all the

00:25:17.920 way to the top of things that they are motivated to do.

00:25:20.940 I think a buddy system is really helpful there.

00:25:23.480 And clearly what's important is to build in the ongoing rewards.

00:25:27.280 I want a person at the end of that exercise bout that they do, let's say on that Sunday

00:25:34.300 morning when they walk with a friend, to talk to their friend about how it felt to exercise.

00:25:40.260 What did you notice?

00:25:41.240 How do you feel now relative to how you felt when you woke up this morning?

00:25:45.180 And attend to those immediate rewards of exercise because we're all motivated to do something

00:25:52.000 if we are rewarded for the activity.

00:25:55.320 And it's our task as provider to figure out where the rewards lie for exercise for people.

00:26:01.640 And it's going to be different for different people.

00:26:04.520 And that's where you have to really have this conversation with the patient about what is

00:26:10.200 it for you and what do you think it will do for you?

00:26:12.640 And can we set it up in a way to where you're going to see the positive effects of exercise for

00:26:18.020 you?

00:26:18.220 Because in the end, when we think about any intervention, whether it's like psychotherapy,

00:26:23.960 where much of the focus is on skills training, or drug therapy, where the prescription is long-term,

00:26:31.640 exercise too, it's not about getting a person to exercise for, let's say, two or three months

00:26:36.440 and say, like, now you're good.

00:26:38.580 With exercise, it really is about getting a person from being a relatively inactive person

00:26:45.060 to become someone who sees exercise and physical activity as part of their life, something that

00:26:52.360 they will do on a weekly or daily basis or whatever fits with their life.

00:26:57.580 They will see themselves as someone who's physically active.

00:27:01.460 And getting a person to that is just requiring that you start slowly and that you get a person

00:27:08.980 excited about this in the sense that they see how this works for them.

00:27:13.940 And what benefits that has emotionally for them, particularly in the beginning.

00:27:19.360 So what do you do with, let's say you got a patient and you did that first week with them,

00:27:23.080 success, they've caught the vision, and they've got this habit of exercise going.

00:27:28.740 But when you're working through any type of mental health issue, you're going to have days

00:27:32.620 that are, you're going to have a setback because of increased stress, et cetera.

00:27:36.080 How do you help your patients prepare for those setbacks so that whenever it comes,

00:27:42.140 they still do that thing, that exercise that can help them?

00:27:46.640 Yeah.

00:27:47.220 Yeah, I'm glad you're bringing that up because nothing is linear typically in the treatment

00:27:54.080 of mental health problems.

00:27:55.260 It isn't like you start at the bottom, so to speak, and then you, in a straight line,

00:28:00.680 move up to where you want to be.

00:28:02.380 Oftentimes, you see some improvements and then you see some dips and then some improvements

00:28:07.100 and then some dips again, lapses or relapses, if you will.

00:28:11.120 And I think it's so important to bring this up with patients at the beginning, that even

00:28:18.240 though we're after initial successes and we are going to build on those successes together

00:28:22.920 and as a provider, I very much act like your coach, much like a gym instructor or a fitness

00:28:30.180 instructor, I know that there are going to be times that your actions didn't line up with

00:28:35.760 your intentions.

00:28:36.760 Like you had set out to go do this particular exercise, but something came up and you didn't

00:28:41.320 or something was really stressful and you said, hey, I'm all out and I'm not going to follow

00:28:46.400 through on this.

00:28:47.720 And that's real and that's going to happen.

00:28:51.260 And setting it up as an expectation and also normalizing that, I think it's just the beginning.

00:28:56.880 And because oftentimes in the dynamic with a provider is also this, I don't want to disappoint

00:29:03.980 this person.

00:29:04.840 And if I am not really doing what we set out to do, well, then maybe this intervention is

00:29:09.860 not right for me.

00:29:11.300 So anticipating this and making this something that is going to be part of that journey moving

00:29:16.940 forward to become a physically active person, that is, there are going to be times that it's

00:29:21.920 not working for you is part of it.

00:29:24.120 And those times that it's not working for them just require more conversations with the

00:29:29.920 provider.

00:29:30.500 And that is like, hey, let's talk about what happened and let's talk about what explains

00:29:35.520 that and let's pick up from there and see what we can do today to pick back up.

00:29:42.320 And if that means, hey, you can start where you left off or we need to do something a little

00:29:46.740 bit different, that's fine.

00:29:48.400 But that sort of flexibility that you have as a provider, but also fund the patient side

00:29:53.940 is what's needed to be effective with this type of intervention.

00:29:57.840 So, I mean, it sounds like you're doing like cognitive behavioral therapy and this helping

00:30:01.560 them exercise, right?

00:30:02.520 So you have to like, okay, they didn't do it.

00:30:04.780 Typically people who are depressed, they have that catastrophizing or like that, well, black 1.00

00:30:10.380 and white thinking.

00:30:11.080 Well, I didn't do what I wanted to do, so I just shouldn't do anything at all.

00:30:14.760 And it's all for naught.

00:30:17.120 Instead, you'd say, hey, well, you didn't do what you wanted to do, but maybe you could

00:30:21.100 just walk for 10 minutes and learn how to be okay with that.

00:30:25.620 Yeah, for sure.

00:30:27.060 I think our CBT skills are really effective when it comes to exercise coaching and managing

00:30:33.020 the exercise program and interpreting the effects and helping patients stay motivated

00:30:39.480 and attending to the cognitions, like you just said.

00:30:43.720 What is it that you're telling yourself right now?

00:30:45.660 Or what are you telling yourself about exercise?

00:30:47.940 Or what are you telling yourself about what's going to happen over the next week?

00:30:51.060 And let's take a look at that together and see if there are different ways of looking

00:30:54.800 at this.

00:30:55.900 Recognizing that oftentimes those predictions or the way that people talk to them are mood-driven.

00:31:01.640 They're very different how you talked about this, let's say, two weeks ago.

00:31:05.080 What does that tell us?

00:31:06.740 And addressing thoughts like that or talking about thoughts like that in that way opens

00:31:13.300 up the possibility that patients can develop some flexibility and say, man, I am really

00:31:17.680 sort of stuck right now.

00:31:18.780 And I find myself, like you said, sort of back where I was before in terms of how I think

00:31:24.760 about myself and this intervention.

00:31:26.860 But you're right.

00:31:27.460 If I look back over the last few weeks when we did this effectively, this is how it worked

00:31:32.860 and perhaps what it takes is X, Y, and Z.

00:31:36.560 And that's an opening again for them to get back and start where they were the previous

00:31:41.480 week or maybe dive into a different set of activities to continue their exercise regimen.

00:31:47.660 You know what's interesting?

00:31:48.280 This stuff works even if you don't have a diagnosed mood disorder.

00:31:51.540 Like this is actually just useful information or skills to have if you're trying to implement

00:31:56.940 any type of healthy habit, whether it's exercise or nutrition, the same sort of thing.

00:32:01.400 It works.

00:32:02.980 I think so.

00:32:03.800 You know, and I, you know, as a psychologist, I work a lot with people who have a disorder

00:32:10.040 like depressive disorder or an anxiety disorder.

00:32:14.160 And, but, you know, most of the patients come to me and they're not like, hey, can you help

00:32:18.940 me get rid of this disorder?

00:32:20.220 And most people, even though that's obviously what they want, they really come to see us because

00:32:26.040 they want a better life and a better life is they want to feel better about themselves.

00:32:31.160 They want to feel better about what the future has to offer for them and all the things that

00:32:36.420 they are involved in.

00:32:37.840 And healthy behaviors are often a big part of that.

00:32:41.340 People tend to feel better when they're physically active.

00:32:43.840 They look at themselves and say like, this is who I am.

00:32:46.480 You know, I use my body.

00:32:47.940 I notice that, you know, that physical pain that I feel a little bit like in terms of,

00:32:52.540 let's say a little muscle ache, that's okay.

00:32:55.640 That's just a signal that I'm actually using my body and I'm being active.

00:32:59.500 And the same is true as you said for nutrition.

00:33:02.520 People tend to feel better when they're, you know, they're, they're eating more healthily

00:33:08.260 than when they don't.

00:33:09.540 So let's talk about another issue that, that springs up with patients when you prescribe

00:33:13.460 exercise for them.

00:33:14.720 So maybe they know that they're going to feel good after it's done.

00:33:17.840 But when they're doing the exercise, particularly if they've been inactive for a really long

00:33:23.780 time, it doesn't feel good while they're doing it because it's just, it's uncomfortable,

00:33:29.740 et cetera.

00:33:30.660 And that can be, that can be unmotivating.

00:33:33.700 In fact, you're like, ah, this doesn't feel good.

00:33:34.940 I'm going to stop.

00:33:35.940 So what do you do with patients there to coach them through that?

00:33:39.720 Yeah, I like you bringing this up.

00:33:41.140 And I think it depends a little bit on the patient.

00:33:43.140 Like actually for some people that not feeling good during exercise can actually be something

00:33:50.240 that is important for their treatment plan is to say like, what can we do actually for

00:33:56.920 you to increase your tolerance of these kinds of sensations and that you actually relate to

00:34:03.800 that type of distress differently.

00:34:06.040 We've done some work on smoking cessation and evaluated an exercise program for smoking

00:34:11.820 cessation, but particularly for people who go back to smoking after they quit because

00:34:18.000 they don't know what to do with those symptoms of withdrawal.

00:34:22.580 And when they experience that, the first thing they do is they go back to their cigarettes

00:34:27.480 because that's how they manage that distress.

00:34:30.040 And in those cases, we find actually it's really helpful to do more of those intense exercises

00:34:35.420 so that people can be more prepared to persist during the times of withdrawal.

00:34:40.440 And so that then becomes a target.

00:34:43.300 Patients then sign up to do that.

00:34:45.680 And then it's working with them to really learn to sort of accept those feelings and stay

00:34:53.560 with the exercise.

00:34:55.060 And it could be little things.

00:34:56.700 It could be sort of that reminder of like, hey, this is why I'm doing this.

00:35:01.320 And this is why I'm actually engaged in this kind of uncomfortable set of exercises.

00:35:08.040 It could be as simple as also sort of practicing the half smile, which is like just sort of notice

00:35:14.380 or be aware of how you're actually showing this kind of distress right now.

00:35:19.700 Is there anything that you can do in terms of your posture or your facial expression that

00:35:24.940 will actually have you relate to this a little bit differently?

00:35:28.420 That's for a particular group of people where the target really is to increase what we call

00:35:33.140 the stress tolerance.

00:35:34.240 But, you know, for most people, like you said, exercise when it's too uncomfortable and it's

00:35:39.520 really not a reason for them to engage in it, like it doesn't necessarily help them with

00:35:45.740 their mood or anxiety goal.

00:35:48.580 Then we do figure out how to make the exercise a bit more interesting, engaging, and less aversive.

00:35:55.320 And so with very few people, actually, I start with intense aerobic exercise.

00:36:01.400 I might work up to that with people, but oftentimes it is actually reducing that.

00:36:05.680 I am totally okay, for example, in the beginning of an exercise regimen, if we get people to just

00:36:11.460 exercise very lightly and just monitor sort of their heart rate, keep it fairly low and sort

00:36:18.260 of say, let's get used to this first.

00:36:19.640 And let's actually make sure that you progress in this training to where you feel like you

00:36:24.880 can handle what is a bit more intense bout down the road.

00:36:29.860 And there's another thing you do too, is sort of doing some problem solving.

00:36:34.740 If you don't, if you feel uncomfortable doing it, like find out ways you can mitigate, like

00:36:38.860 you're still feeling uncomfortable, but it's not as bad.

00:36:41.620 So, I mean, I guess an example I thought of, like play a team sport, do something with a

00:36:44.740 group, right?

00:36:45.600 So if for some reason, whenever you're suffering with other people, it somehow weirdly reduces

00:36:50.360 the suffering and it kind of is motivating to see someone else is doing that, that might

00:36:54.980 be another option as well.

00:36:57.100 Oh, for sure.

00:36:57.900 I like that suggestion a lot that what are some of the ways in which you can make the exercise

00:37:03.360 more tolerable?

00:37:04.840 Certainly doing exercise with other people for many will do that.

00:37:09.500 If it's a group exercise for some, it actually makes it a little bit more challenging.

00:37:13.200 Those people who have, let's say, social anxiety problems, they sometimes find it actually a

00:37:18.740 bit more challenging to exercise with other people.

00:37:21.340 But yeah, you're right.

00:37:22.560 You want to figure out ways in which people can engage with the activity to where it's

00:37:29.260 going to be a little bit more interesting.

00:37:31.400 So they will notice the activation, the physiological activation, yet that's not all that they notice.

00:37:37.840 They also notice their friend around them or, you know, if they're alone, they will be listening

00:37:43.980 to, let's say, a book or a podcast and you teach them to really engage with that as well.

00:37:51.060 It's like, what are you hearing there?

00:37:52.360 So can you do two things at the same time, which is you are experiencing that distress and

00:37:58.580 at the same time, you're also able to actually listen to, let's say, a podcast or listen to

00:38:03.460 your favorite playlist.

00:38:05.240 And so it is, again, personalized where you work with the patient to figure out, well,

00:38:10.140 what does it take for you?

00:38:11.340 What would it take for you to be okay with the activation and also engage or notice the other

00:38:18.400 things that are around you that are interesting and important to you as you participate in the

00:38:24.320 physical activity?

00:38:25.880 Yeah, as soon as you brought that up, doing something that you enjoy while you're actually

00:38:29.120 there.

00:38:29.240 We had Katie Milkman on the podcast a while ago about talking about temptation bundling

00:38:33.580 and she mentioned that if you don't like to exercise, well, then you do something, you

00:38:37.180 set something up where, well, I can only listen or like watch this movie that I really love

00:38:42.520 when I'm on the treadmill.

00:38:44.560 That's the only, and then that can be a motivator to, to get on the treadmill or do whatever

00:38:48.380 or take a walk or whatever.

00:38:50.140 I do that for sure for the exercises that I don't particularly like to do.

00:38:54.840 I do some strength training and I really don't find it that interesting or.

00:38:59.240 It doesn't feel very good, but it is the time that I listen to my favorite podcast and it

00:39:05.540 might take me a little longer to get through it because I want to listen to both the podcasts,

00:39:08.960 but I know that I get both in, which is, you know, the podcast time.

00:39:13.620 And while I'm doing that, I actually got that particular exercise or set of exercises done.

00:39:20.140 And so I like tying activity to other rewarding activities, whether that's something that you

00:39:26.920 like to do for yourself or whether it's something that you like to do with other people.

00:39:31.000 And so look for those things that make it more motivating for you and more likely that you

00:39:35.980 actually get something out of it.

00:39:38.140 So yeah, again, the goal is like, enjoy yourself.

00:39:40.060 Don't think of it just as like medicine that you have to take, make it something that you

00:39:43.420 can enjoy and can be a part of your life for the long run.

00:39:46.720 Oh, for sure.

00:39:47.500 And I think that's definitely what you want to work and what we work toward with our patients.

00:39:53.660 It may not be there in the beginning when we just set up those initial successes, but

00:39:58.240 as we are trying to build a habit, like something that's going to last over time, we do want

00:40:04.960 it to be something that's enjoyable.

00:40:07.700 And to your point earlier, how do you anticipate the things that, you know, might change over time?

00:40:14.400 That also will change over time.

00:40:16.400 A lot of people won't like an activity for very long.

00:40:20.880 They might like, let's say, running for a little bit, but at some point they get kind

00:40:25.900 of sick of it.

00:40:26.560 So you want to stay flexible, anticipate that and say like, over time, your exercise regimen,

00:40:33.720 the set of activities that you engage in might change and you'll stay open-minded and curious

00:40:39.440 to other activities that you will use to replace the ones that you're sort of bored with.

00:40:44.400 Or no longer find interesting, or you develop new friendships, or all of a sudden you're

00:40:49.480 exercising with your family, like you might exercise with your kids, or you might exercise

00:40:53.120 with your spouse.

00:40:54.080 All these things that keep it interesting and keep it something that is enjoyable over time

00:40:59.560 and stay flexible that it might take lots of changes along the way.

00:41:04.320 And that's where I think sometimes providers can be really helpful is to stay creative, help

00:41:11.460 troubleshoot, and come up with ideas that people can implement to keep their habit alive and

00:41:17.500 active over time.

00:41:18.980 Well, Jasper, this has been a great conversation.

00:41:20.640 Is there some place people can go to learn more about the book and your work?

00:41:23.480 I think the book is just on Amazon, and that's probably the best access for people to get

00:41:29.180 a sense of how to think about exercise and how to incorporate in their life as they have

00:41:35.320 goals for improving their well-being.

00:41:37.480 Fantastic.

00:41:37.840 Well, Jasper Smits, thanks for your time.

00:41:39.040 It's been a pleasure.

00:41:40.020 Thank you.

00:41:40.780 I enjoyed it.

00:41:41.880 My guest name is Dr. Jasper Smits.

00:41:43.360 He's the co-author of the book, Exercise for Mood and Anxiety.

00:41:46.420 It's available on Amazon.com.

00:41:47.760 Make sure to check out our show notes at awim.is slash exercise for mood, where you can find

00:41:51.460 links to resources, where you can delve deeper into this topic.

00:42:00.860 Well, that wraps up another edition of the AOM Podcast.

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00:42:56.460 Thank you.

The Art of Manliness - September 20, 2021

The Exercise Prescription for Depression and Anxiety

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