Estilo de Vida Como Terapia Roger Walsh 2

Lifestyle and Mental Health
Roger Walsh, M.D., Ph.D.
Editor’s Note. We are thankful for Roger Walsh amassing a wealth of literature in this article to support the
use of therapeutic lifestyle changes. This is crucial information to use in the integration phase of the Hakomi
model to bridge the transformation of core beliefs into congruent habits and lifestyle changes that support the
establishment of new neural networks that undergird long-term change. The article was originally published in
the American Psychologist (2011, Vol. 66, No. 7, pp. 579–592), and is used with permission.
Roger Walsh M.D., Ph.D. is a professor at the University of California Medical School, editor of The World’s
Great Wisdom: Humanity’s Heritage of Timeless Teachings, and author of Essential Spirituality: The
7 Central Practices to Awaken Heart and Mind. He has made lifelong contributions to the interface of
spirituality and therapy, and has been a key contributor to the work of the Integral Institute.
Abstract
Mental health professionals have significantly underestimated the importance of lifestyle factors
as contributors to and treatments of multiple psychopathologies, for fostering individual
and social wellbeing, and for preserving and optimizing cognitive function. Consequently,
therapeutic lifestyle changes (TLCs) are underutilized, despite considerable evidence of their
effectiveness in both clinical and normal populations. TLCs are sometimes as effective as
either psychotherapy or pharmacotherapy, and can offer significant therapeutic advantages.
Important therapeutic lifestyle changes include exercise, nutrition and diet, time in nature,
relationships, recreation, relaxation and stress management, religious/spiritual involvement, and
service to others. This article reviews research on their effects and effectiveness, the principles,
advantages, and challenges of implementing them, and the forces (economic, institutional, and
professional) hindering their use. Where possible, therapeutic recommendations are distilled
into easily communicable principles, since such ease strongly influences whether therapists
recommend and patients adopt interventions. Finally, the article explores the many implications
of contemporary lifestyles and therapeutic lifestyle changes for individuals, society, and health
professionals. In the 21st century, therapeutic lifestyles may need to be a central focus of mental,
medical, and public health.
Key Words
Lifestyle, therapeutic lifestyle changes, mental health, psychopathology, cognitive capacities
Lifestyle and Mental Health

The central thesis of this article is very simple: Health pro- Greater awareness of lifestyle factors offers major advan-
fessionals have significantly underestimated the importance tages, yet few health professionals are likely to master the
of lifestyle for mental health. More specifically, mental multiple burgeoning literatures. This article, therefore,
health professionals have underestimated the importance reviews research on the effects and effectiveness of eight
of unhealthy lifestyle factors in contributing to multiple major therapeutic lifestyle changes; the principles, advan-
psychopathologies, as well as the importance of healthy tages, and challenges of implementing them; the factors
lifestyles for treating multiple psychopathologies, for foster- hindering their use; and the many implications of contem-
ing psychological and social wellbeing, and for preserving porary lifestyles for both individuals and society.
and optimizing cognitive capacities and neural functions.
Lifestyle factors can be potent in determining both physical
Hakomi Forum, 2014-2015, Issue 27 17

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and mental health. In modern affluent societies, the dis- Advantages of Therapeutic Lifestyle Changes
eases exacting the greatest mortality and morbidity—such
Lifestyle changes can offer significant therapeutic advan-
as cardiovascular disorders, obesity, diabetes, and cancer—
tages for patients, therapists, and societies. First, TLCs can
are now strongly determined by lifestyle. Differences in just
be both effective and cost-effective, and some—such as
four lifestyle factors—smoking, physical activity, alcohol
exercise for depression, and fish oils to prevent psychosis in
intake, and diet—exert a major impact on mortality, and
high risk youth—may be as effective as pharmacotherapy
“even small differences in lifestyle can make a major differ-
or psychotherapy (Amminger et al, 2010; Dowd, Vickers,
ence in health status” (Khaw, Wareham, Bingham, Welch,
& Krahn, 2004; Sidhu et al., 2009). TLCs, which can be
& Luben, 2008, p. 376).
used alone or adjunctively, are often accessible and afford-
Therapeutic lifestyle changes (TLCs) can be potent. They able, and many can be introduced quickly, sometimes even
can ameliorate prostate cancer, reverse coronary arterio- in the first session (McMorris, Tomporouski & Audiffren,
sclerosis, and be as effective as psychotherapy or medica- 2009).
tion for treating some depressive disorders (Frattaroli et
Therapeutic lifestyles have few negatives. Unlike both psy-
al., 2009; Pischke, Scherwitz, Weidmer & Ornish, 2008;
chotherapy and pharmacotherapy, they are free of stigma,
Sidhu, Vandana, & Balon, 2009). Consequently, there is
and can even confer social benefits and social esteem (Bor-
growing awareness that contemporary medicine needs to
gonovi, 2009). In addition, they have fewer side effects and
focus on lifestyle changes for primary prevention, second-
complications than medications (Amminger et al., 2010).
ary intervention, and to empower patients’ self-manage-
ment of their own health. Therapeutic lifestyles offer significant secondary benefits to
patients, such as improvements in physical health, self-
Mental health professionals and their patients have much
esteem, and quality of life (Deslandes et al, 2009). Further-
to gain from similar shifts. Yet the importance of TLCs are
more, some TLCs—for example, exercise, diet and medita-
insufficiently appreciated, taught, or utilized. In fact, in
tion—may also be neuroprotective, and reduce the risk of
some ways, mental health professionals have moved away
subsequent age-related cognitive losses and corresponding
from effective lifestyle interventions. Economic and insti-
neural shrinkage (Hamer & Chida, 2009; Pagnoni &
tutional pressures are pushing therapists of all persuasions
Cekis, 2007; Raji et al., 2009). Many TLCs—such as
towards briefer, more stylized interventions. Psychiatrists in
meditation, relaxation, recreation¸ and time in nature—are
particular are being pressured to offer less psychotherapy,
enjoyable, and may therefore become healthy self-sustain-
prescribe more drugs, and focus on fifteen minute “med
ing habits (Didonna, 2009).
checks,” a pressure that psychologists who obtain prescrip-
tion privileges will doubtless also face (Mojtabai & Olfson, Many TLCs not only reduce psychopathology but can also
2008). As a result, patients suffer from inattention to com- enhance health and wellbeing. For example, meditation
plex psychodynamic and social factors while therapists can can be therapeutic for multiple psychological and psycho-
suffer painful cognitive dissonance and role strain when somatic disorders (Chiesa, 2009; Didonna, 2009; Shapiro
they shortchange patients who need more than mandated & Carlson, 2009). Yet it can also enhance psychological
brief treatments allow (Luhrmann, 2001). wellbeing and maturity in normal populations, and culti-
vate qualities such as calm, empathy, and self-actualization
A further cost of current therapeutic trends is the under-
that are of particular value to clinicians (Shapiro & Carl-
estimation and underutilization of lifestyle treatments
son, 2009; Shapiro & Walsh, 2006; Walsh, in press).
(Angell, 2009), despite considerable evidence of their effec-
tiveness. In fact, the need for lifestyle treatments is grow- Knowledge of TLCs can benefit clinicians in several ways.
ing, since unhealthy behaviors such as overeating and lack Utilizing TLCs may result in greater clinical flexibility
of exercise are increasing to such an extent that the World and effectiveness and less role strain. It will be particularly
Health Organization (2008) warns that “an escalating interesting to see to what extent clinicians exposed to
global epidemic of overweight and obesity—‘globesity’—is information about TLCs adopt healthier lifestyles them-
taking over many parts of the world,” and exacting enor- selves and, if so, how this affects their professional practice,
mous medical, psychological, social, and economic costs. since there is already evidence that therapists with healthy
lifestyles are more likely to suggest lifestyle changes to
their patients (McEntee & Haglin, 1996). There are also
entrepreneurial opportunities. Clinics are needed which
offer systematic lifestyle programs for mental health similar
18 Issue 27, 2014–2015, Hakomi Forum

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to current programs for reversing coronary artery disease 2002; Deslandes et al., 2009; Stathopoulou, Powers, Berry,
(Pischke et al., 2008). Smits, & Otto, 2006).
For societies, TLCs may offer significant community and The most studied disorder is mild to moderate depression.
economic advantages. Economic benefits can accrue from Cross-sectional, prospective, and meta-analytic studies
reducing the costs of lifestyle related disorders such as suggest that exercise is both preventive and therapeutic,
obesity, which alone costs over $100 billion in the United and therapeutically it compares favorably with pharmaco-
States each year (WHO, 2008). Community benefits therapy and psychotherapy (Dowd et al., 2004; Sidhu et
can occur both directly, e.g. through enhanced personal al., 2009). Both aerobic exercise and nonaerobic weight
relationships and service (Post, 2007), and also indirectly training are effective for both short-term interventions
through social networks. Recent research demonstrates and long-term maintenance, and there appears to be a
that healthy behaviors and happiness can spread exten- dose-response relationship with higher intensity workouts
sively through social networks, even through three degrees being more effective. Exercise is a valuable adjunct to
of separation to, for example, the friends of one’s friends’ pharmacotherapy, and special populations such as postpar-
friends (Fowler & Christakis, 2008; 2010). Encouraging tum mothers, the elderly, and perhaps children appear to
TLCs in patients may therefore inspire similar healthy benefit (Hamer & Chida, 2008; Larun, Nordeim, Ekeland,
behaviors and greater wellbeing in their family, friends, and Hagen, & Heian, 2006; Sidhu et al., 2009).
coworkers, and thereby have far reaching multiplier effects Possible mediating factors that contribute to these anti-
(Christakis, 2009; Fowler & Christakis, 2010). This offers depressant effects span physiological, psychological, and
novel evidence for the public health benefits of mental neural domains. Proposed physiological mediators in-
health interventions in general, and of TLCs in particular. clude changes in serotonin metabolism, improved sleep,
So what lifestyle changes warrant consideration? Consider- as well as endorphin release and consequent “runner’s
able research and clinical evidence support the following high” (Deslandes et al., 2009; Stathopoulou et al., 2006).
eight TLCs: exercise, nutrition and diet, time in nature, Psychological factors include enhanced self-efficacy and
relationships, recreation, relaxation and stress management, self-esteem, interruption of negative thoughts and rumina-
religious and spiritual involvement, as well as contribution tion (Dowd et al., 2004), and perhaps the breakdown of
and service to others. “muscular armor”: the chronic psychosomatic muscle ten-
sion patterns that express emotional conflicts, and that are
Exercise a focus of somatic therapies (Smith, 2000).
Exercise offers physical benefits that extend over multiple Neural factors are especially intriguing. Exercise increases
body systems. It reduces the risk of multiple disorders, brain volume (both grey and white matter), vasculariza-
including cancer, and is therapeutic for physical disorders tion, blood flow, and functional measures (Erikson &
ranging from cardiovascular diseases to diabetes to prostate Kramer, 2009; Hamer & Chida, 2009). Animal studies
cancer (Khaw et al., 2009; Ornish et al., 2008). Exercise suggest that exercise-induced changes in the hippocampus
is also, as the Harvard Mental Health Letter (September include increased neuronogenesis, synaptogenesis, neuro-
2000) concluded, “a healthful, inexpensive, and insuffi- nal preservation, interneuronal connections, and BDNF
ciently used treatment for a variety of psychiatric disorders” (brain-derived neurotrophic factor, the same neurotrophic
(p. 5). factor that antidepressants upregulate) (Cotman & Berch-
As with physical effects, exercise offers both preventive and told, 2002).
therapeutic psychological benefits. Preventively, both cross- Given these neural effects, it is not surprising that exercise
sectional and prospective studies show that exercise can can also confer significant cognitive benefits (McMorris,
reduce the risk of depression, as well as neurodegenerative Tomporowski & Audiffren, 2009). These range from en-
disorders such as age-related cognitive decline, Alzheimer’s hancing academic performance in youth, to aiding stroke
and Parkinson’s diseases (Hamer & Chida, 2009; Sui et al., recovery, to reducing age-related memory loss and the risk
2009). Therapeutically, responsive disorders include de- of both Alzheimer’s and nonAlzheimer’s dementia in the
pression, anxiety, eating, addictive, and body dysmorphic elderly (Hamer & Chida, 2009; Quaney et al., 2009).
disorders. Exercise also reduces chronic pain, age-related Multiple studies show that exercise is a valuable therapy
cognitive decline, severity of Alzheimer’s, and some symp- for Alzheimer’s’ patients that can improve intellectual
toms of schizophrenia (Colcombe & Kramer, 2003; Daley, capacities, social functions, emotional states, and caregiver
distress (Christofoletti et al., 2007; Deslandes et al., 2009).

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Meta-analytic studies provide more fine-grained details patients adopt treatments (Duncan, Miller, Wampold &
about the cognitive benefits of exercise for the elderly, Hubble, 2010). Two major dietary components must be
and offer four kinds of good news. First, the effects can considered: food selection and supplements.
be large, reducing the risk of Alzheimer’s by 45%, and
increasing cognitive performance by 0.5 SD (Hamer & Food Selection
Chida, 2009). Second, though women may gain more than For food selection, the key principles are to emphasize a
men, everyone seems to benefit, including both clinical diet that:
and nonclinical populations. Third, improvements extend
over several kinds of psychological functions, ranging from 1. Consists predominantly of multicolored fruits and
processing speed to executive functions. Fourth, executive vegetables (a “rainbow diet”),
functions, such as coordination and planning, appear to 2. Contains some fish (a “pescovegetarian diet”). Prefer-
benefit most. This is a welcome finding given that execu- ence should be given to cold deep seawater fish (which
tive functions are so important, and that both they and the are high in beneficial omega-3 fish oils, e.g. salmon),
brain areas that underlie them are particularly age sensitive while avoiding the four species with high mercury
(Colcombe & Kramer, 2003; Erikson & Kramer, 2009). levels (shark, swordfish, king mackerel, and tilefish)
Finally, meta-analyses reveal the specific elements of exer- (Oken et al., 2008).
cise that benefit cognition. Relatively short programs of 3. Reduces excessive calories. For societies confronting
1-3 months offer significant benefits, though six months or the “globesity” epidemic, reducing excess calories offers
longer are more beneficial. There seems to be a threshold both economic and public health benefits (Delpeuch,
effect for session duration, since sessions shorter than 30 Marie, Monnnier & Holdsworth, 2009). For indi-
minutes—while valuable for physical health—yield mini- viduals, reducing excess calories offers medical and
mal cognitive gains. Cognitive benefits are enhanced by neuroprotective benefits (Prolla & Mattson, 2001).
more strenuous activity, and by combining strength train- This neuroprotection is especially important in light
ing with aerobics (Colcombe & Kramer, 2003; Hertzog, of recent findings suggesting that adult obesity may be
Kramer, Wilson, & Lindenberger, 2009). In short, research associated with reduced cognitive function, as well as
validates the words of the second U.S. president, John reduced white and gray matter brain volume (Raji et
Adams, who wrote that “Old minds are like old horses; you al., 2009; Wolf et al., 2007). Fortunately, pescovegetar-
must exercise them if you wish to keep them in working ian diets are low in calories.
order” (Hertzog et al., 2009, p. 26). Multiple human and animal studies suggest that pescov-
Fortunately, even brief counseling can motivate many pa- egetarian diets may prevent or ameliorate psychopatholo-
tients to exercise (Long et al., 1996) and risks are minimal, gies across the life span (Gomez-Pinilla, 2008; Willis,
although an initial medical exam may be warranted. Yet Shukitt-Hale, & Joseph, 2009). Such diets may enhance
despite the many mental and medical benefits of exercise, cognitive and academic performance in children, as well as
only some ten percent of mental health professionals rec- ameliorate affective and schizophrenic disorders in adults.
ommend it. And who are these ten percent? Not surpris- They also offer neuroprotective benefits as demonstrated by
ingly, they are likely to exercise themselves (McEntee & reductions in the incidence of age-related cognitive de-
Halgin, 1996). cline, Alzheimer’s and Parkinson’s diseases (Gomez-Pinilla,
2008; Kang, Ascherio, & Groodstein, 2005; Morris, Evans,
Nutrition and Diet Tangney, Bienias, & Wilson, 2006). Several studies of the
There is now considerable evidence of the importance of Mediterranean diet—including a meta-analysis of twelve
nutrition for mental health, and an extensive review of over prospective studies with over 1.5 million subjects—found
160 studies suggests that dietary factors are so important reductions in incidence of both Alzheimer’s and Parkinson’s
that the mental health of nations may be linked to them diseases (Sofi, Cesari, Abbate, Gensini, & Casini, 2008).
(Gomez-Pinilla, 2008). Given the enormous literature on Dietary elements that appear to be particularly neuropro-
this topic, it is easy to feel overwhelmed. Therefore, the tective include fish, vegetables, and perhaps fruit, as well as
following section reviews this complex literature, but also lower intake of animal fats (Gu, Nieves, Stern, Luchsinger,
distills easily communicable principles, since such ease & Scarmeas, 2010; Kang et al., 2005; Morris et al., 2006).
strongly influences whether therapists recommend and Of enormous public health importance are recent findings

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suggesting that due to epigenetic factors, “the effects of diet There are also cognitive benefits. In infants, both maternal
on mental health can be transmitted across generations” intake and feeding formula supplementation enhance chil-
(Gomez-Pinilla, 2008, p. 575). dren’s subsequent cognitive performance (Freeman et al.,
2006; Gomez-Pinilla, 2008; Innis, 2009;). In older adults,
Supplements fish and fish oil supplements appear to reduce cognitive
Growing evidence suggests that food supplements offer decline, but do not seem effective in treating Alzheimer’s
valuable prophylactic and therapeutic benefits for mental (Fotuhi, Mohassel, & Yaffe, 2009).
health. Research is particularly being directed to vitamin The evidence on omega-3s for other disorders is promis-
D, folic acid, SAME (S-adenosyl-methionine), and most of ing, but less conclusive. Supplementation may benefit
all to fish oil (Sarris, Schoendorfer, & Kavanagh, 2009). schizophrenia and Huntington’s disease, as well as aggres-
Fish and fish oil are especially important for mental health. sion in both normal and prison populations. In children,
They supply essential omega-3 fatty acids, especially EPA omega-3s may reduce aggression and symptoms of ADHD
(eicosapentaenoic acid) and DHA (docosahexaenoic acid), (Freeman et al., 2006; Song & Zhao, 2008).
which are essential to neural function. Systemically, omega- A particularly important finding is that fish oils may
3s are anti-inflammatory, counteract the proinflamatory prevent progression to first episode psychosis in high risk
effects of omega-6 fatty acids, and are protective of mul- youth. A randomized, double-blind, placebo-controlled
tiple body systems. Unfortunately, modern diets are often study was conducted of 81 youths between 13 and 25 years
high in omega-6s and deficient in omega-3s (Freeman et of age with subthreshold psychosis. Administering fish oil
al., 2006) . with 1.2g of omega-3s per day for 12 weeks reduced both
Is this dietary deficiency associated with psychopathol- positive and negative symptoms as well as the risk of pro-
ogy? Both epidemiological and clinical evidence suggest it gression to full psychosis. This risk was 27.5% in controls
is. Affective disorders have been most closely studied, and but fell to only 4.9% in treated subjects. Particularly im-
epidemiological studies, both within and between coun- portant was the finding that benefits persisted during the 9
tries, suggest that lower fish consumption is associated with months of follow up after treatment cessation (Amminger
significantly, sometimes dramatically, higher prevalence et al., 2010). Such persistence has not occurred with anti-
rates of these disorders (Freeman et al., 2006; Noaghuil & psychotic medications, which also have significantly more
Hibbeln, 2003). Likewise, lower omega-3 tissue levels are side effects. Although only a single study, these findings
correlated with greater symptom severity in both affec- suggest another important prophylactic benefit of fish oils.
tive and schizophrenic disorders, a finding consistent with With one exception, risks of fish oil supplementation at
emerging evidence that inflammation may play a role in recommended doses are minimal, and usually limited to
these disorders (Amminger et al., 2010) . However, epide- mild gastrointestinal symptoms. The exception is patients
miological studies of dementia and omega-3 intake are as on anticoagulants or with bleeding disorders because fish
yet inconclusive (Freeman et al., 2006). oils can slow blood clotting. Such patients should therefore
Epidemiological, cross-sectional, and clinical studies sug- be monitored by a physician.
gest that omega-3 supplementation may be therapeutic for Omega-3s modify genetic expression, and as such are early
several disorders. Again, depression has been most closely exemplars of a possible new field of “psychonutrigenom-
studied (Stahl, Begg, Weisinger, & Sinclair, 2008). Several ics.” Nutrigenomics is an emerging discipline that uses
meta-analyses suggest that supplementation may be effec- nutrients to modify genetic expression (Gillies, 2007).
tive for unipolar, bipolar, and perinatal depressive disorders Since genetic expression is proving more modifiable, and
as an adjunctive, and perhaps even as a stand-alone treat- nutrients more psychologically important than previously
ment (Appleton, Rogers & Ness, 2010; Lin & Su, 2007), thought, psychonutrigenomics could become an important
though at this stage supplementation is probably best used field.
adjunctively. Questions remain about optimal DHA and Space limitations allow only brief mention of another sig-
EPA doses and ratios, although one meta-analysis found a nificant supplement, vitamin D. Vitamin D is a multipur-
significant correlation between dose and treatment effect, pose hormone with multiple neural functions, including
and a dose of 1000 mg of EPA daily is often mentioned, neurotrophic, antioxidant, and anti-inflammatory effects.
which requires several fish oil capsules (Freeman et al., (Cherniak, Troen, Florez, Roos, & Levis, 2009). Vitamin
2006; Kraguljac et al., 2009). D deficiency is widespread throughout the population,

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especially in the elderly, exacts a significant medical toll, diurnal rhythms. Cognitive costs include short term im-
and several studies suggest associations with cognitive pairment of attention and cognition, as well as long term
impairment, depression, bipolar disorder, and schizophre- reduced academic performance in the young, and greater
nia. Mental health professionals are therefore beginning to cognitive decline in the elderly (Anthes, 2009; Higgins,
join physicians in recommending routine supplementation Hall, Wall, Woolner, & McCaughey, 2005; Kuller, Ballal,
(usually 400-1,000 units per day), and where indicated Laike, Mikellides, & Tonello, 2006). Further psychological
testing patients’ vitamin D blood levels and modifying difficulties occur in special populations such as Alzheimer’s
supplement levels accordingly (Cherniak et al, 2009). and post-surgical patients (Anthes, 2009; Ulrich, 2006).
There are further benefits to supplementation and pesco-
Media Immersion and Hyper-reality
vegetarian diets. First, they have multiple general health
benefits and low side effects. Second, they may ameliorate In the last half century, a further artificial dimension has
certain comorbid disorders—such as obesity, diabetes, and been added. Increasingly, we now spend hours each day
cardiovascular complications—that can accompany some immersed in a flood of multimedia stimuli, whose neu-
mental illnesses and medications. A diet that is good for rological impact we are only beginning to understand.
the brain is good for the body. As such, dietary assessment However, some researchers have already concluded that
and recommendations are appropriate and important ele- “The current explosion of digital technology not only is
ments of mental health care. changing the way we live and communicate but also is
rapidly and profoundly changing our brains” (Small &
Nature Vorgan, 2008, p. 44). This is hardly surprising given that
Imagine a therapy that had no known side effects, was the average American spends several hours a day watching
readily available, and could improve your cognitive func- television, and increasing time with digital media (Putnam,
tioning at zero cost. Such a therapy has been known to 2000). As Thoreau (1854) lamented, people “have become
philosophers, writers, and laypeople alike: interacting with the tools of their tools” (p. 85).
nature. Many have suspected that nature can promote Fortunately, television and digital media can sometimes be
improved cognitive functioning and overall well-being, beneficial. Multiple meta-analyses show that while aggres-
and these effects have recently been documented (Berman, sive television content can certainly foster negative atti-
Jonides, & Kaplan, 2008, p. 1207). tudes and aggressive behavior, prosocial content can foster
For thousands of years, wise people have recommended positive behavior such as altruism (Mares & Woodard,
nature as a source of healing and wisdom. Shamans seek 2005; Preiss, Gayle, Burrell, Allen & Bryant, 2006). Like-
wilderness, yogis the forest, Christian Fathers the desert, wise, digital immersion can benefit certain psychological
and American Indians go on nature vision quests. Their and social skills in children, as the massive Digital Youth
experience is that nature heals and calms, removes men- Project demonstrated (Ito et al., 2008).
tal trivia, and reminds us of what really matters (Walsh, However, media immersion can also exact significant psy-
1999). More recently, romantic and existential philoso- chological and physical costs in both children and adults,
phers echoed similar claims, which the romantic poet Wil- and a novel vocabulary has emerged to describe multiple
liam Wordsworth (1998) famously summarized as: “technopathologies.” Excessive media immersion, especially
Getting and spending we lay waste our powers when combined with heavy work demands, can create
Little we see in nature that is ours; psychological dysfunctions that include disorders of:
We have given our hearts away…. (p. 307) Attention: continuous partial attention and attention deficit
Yet today we are conducting a global experiment in which trait.
we increasingly spend our lives in artificial environments: Cognition: digital fog and techno-brain burnout.
walled inside and divorced from nature. Within these Overload: data smog and frazzing (frantic ineffectual multi-
nature-free settings, noise is often annoying, and lighting is tasking).
often artificial, low intensity (often less than 10% of sunny
days), with nonnatural spectra and rhythms. As the bur- Addiction: screen sucking and on-line compulsive disorder.
geoning field of environmental psychology demonstrates, And, of course, techno-stress (Small & Vorgan, 2008;
the psychological costs of such settings can be wide-rang- Wehrenberg & Coppersmith, 2008)
ing. These costs include disruptions of mood, sleep, and Yet the full implications of contemporary media and our

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divorce from nature may extend much further and cut far (Maller, Townsend, Pryor, Brown, & Sleger, 2006).
deeper than individual stress and pathology. There is an ex- Nature also offers the gift of silence. Modern cities abound
ploding literature on social effects (e.g., Bracken & Skalski, in strident sounds and noise pollution, and the days when
2009), and so powerful and pervasive is today’s multimedia Henry Thoreau (1921) could write of silence as a “univer-
reality, that for philosophers such as Jean Baudrillard, it sal refuge…a balm to our every chagrin” (p. 291) are long
constitutes a “hyper-reality”—a simulated life-world that gone. Unfortunately, urban noise can exact significant cog-
seems “more real than reality.” So omnipresent are media nitive, emotional, and psychosomatic tolls. These range, for
manufactured images and narratives, and so divorced are example, from mere annoyance to attentional difficulties,
we from the direct events they portray, that we largely sleep disturbances, and cardiovascular disease in adults,
live in, believe in, and respond to, this artificial hyper-real and impaired language acquisition in children (Clark &
world, rather than to the natural world itself (Tiffin & Stansfeld, 2007). By contrast, natural settings offer silence
Terashima, 2001). as well as natural sounds and stimuli that attention restora-
tion theory and researchers suggest are restorative (Berman
Evolutionary, Existential, and Clinical Concerns
et al., 2008).
We have barely begun to research the many implications As yet, studies of specific psychotherapeutic benefits are
of artificial environments, new media, hyper-reality, and limited, and sometimes conflated with other therapeutic
our divorce from nature. However, the problems they lifestyle factors. Though further research is clearly needed,
may pose can be viewed in multiple ways. Biologically, immersion in nature does appear to reduce symptoms of
we may be adapted to natural living systems and to seek stress, depression, and ADHD, and to foster community
them out. This is the “biophilia hypothesis,” and multiple benefits (Taylor & Kuo, 2009; Taylor, Kuo, & Sullivan,
new fields—such as diverse schools of ecology, as well as 2001). In hospital rooms that offer views of natural set-
evolutionary, environmental, and eco psychologies—argue tings, patients experience less pain and stress, have better
for an intimate and inescapable link between mental health mood and postsurgical outcomes, and are able to leave the
and the natural environment (Esbjorn-Hargens & Zim- hospital sooner (Devlin & Arneill, 2003; Ulrich, 2006).
merman, 2009). In existential terms, the concern is that Consequently, nature may be “…one of our most vital
“…modern man—by cutting himself off from nature has health resources” (Maller et al., 2006, p. 62). Given the
cut himself off from the roots of his own Being” (Barrett, global rush of urbanization and technology, the need for
1962, p. 126), thereby producing an existential and clinical mental health professionals to advocate for time in, and
condition generically described as “nature-deficit disorder” preservation of, natural settings will likely become increas-
(Louve, 2005). ingly important.
Clinicians harbor multiple concerns. Evolutionary and
developmental perspectives suggest that children in envi- Relationships
ronments far different from the natural settings in which Of all the means which are procured by wisdom to ensure
we evolved, and to which we adapted, may suffer devel- happiness throughout the whole of life, by far the most
opmental disorders, with ADHD as one possible example important is the acquisition of friends.
(Bjorklund & Pellegrini, 2002). Likewise, evolutionary
theory and cross-cultural research suggest that for adults, —Epicurus (Gordon, 1999, p. 35).
artificial environments and lifestyles may impair mental The idea that good relationships are central to both physi-
wellbeing, and also foster or exacerbate psychopathologies cal and mental wellbeing is an ancient theme, now sup-
such as depression (Buss, 2000). ported by considerable research. Rich relationships reduce
health risks ranging from the common cold to stroke,
Therapeutic Benefits of Nature mortality, and multiple psychopathologies. On the posi-
Fortunately, natural settings can enhance both physical tive side, good relationships are associated with enhanced
and mental health. In normal populations, these enhance- happiness, quality of life, resilience, cognitive capacity, and
ments include greater cognitive, attentional, emotional, perhaps even wisdom (Fowler & Christakis, 2008; Jetten,
spiritual, and subjective wellbeing (Ho, Payne, Orsega- Haslam, Haslam, & Branscombe, 2009). Analyses of dif-
Smith, & Godby, 2003; Pryor, Townsend, Maller, & Field, ferent domains of life indicate that quality of life is “domi-
2006). Benefits also occur in special populations such as nated by the domain of intimacy” and that people with
office workers, immigrants, hospital patients, and prisoners overt psychopathology have a lower quality of life “most

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particularly in the domain of intimacy” (Cummins, 2005, connections and networks that link people and foster, for
p. 559). example, beneficial social engagement, support, trust, and
These clinical observations can now be grounded in the reciprocity (Bhandari & Yasunobu, 2009). Social capital
emerging field of social neuroscience, which suggests that seems positively and partly causally related to a wide range
we are interdependent creatures, hardwired for empathy of social health measures—such as reduced poverty, crime,
and relationship through, for example, the mirror neu- and drug abuse—as well as increased physical and mental
ron system (Cattaneo & Rizzolatti, 2009). So powerful is health in individuals. Yet considerable evidence suggests
interpersonal rapport that couples can mold one another that social capital in the United States and other societies
both psychologically and physically. They may even come may have declined significantly in recent decades (Putnam,
to look more alike, as resonant emotions sculpt their facial 1995, 2000).
muscles into similar patterns, a process known as “the Mi- In short, relationships are of paramount importance to
chelangelo phenomenon” (Rusbult, Finkel & Kumashiro, individual and collective wellbeing, yet the number and
2009). intimacy of relationships seems to be declining. Moreover,
Not surprisingly, good relationships are crucial to psycho- “the great majority of individuals seeking therapy have
therapy. Multiple meta-analyses show that they account for fundamental problems in their relationships…” (Yalom,
approximately one-third of outcome variance, significantly 2002, p. 47). Clients’ relationships are a major focus of, for
more than does the specific type of therapy (Duncan et example, interpersonal and some psychodynamic psycho-
al., 2010), and that “The therapeutic relationship is the therapies (Shedler, 2010). Yet clients’ interpersonal rela-
cornerstone” of effective therapy (Norcross, 2010, p. 114). tionships often receive insufficient attention in clinical and
As Irvin Yalom (2002) put it, the “paramount task is to training settings compared to intrapersonal and pharmaco-
build a relationship together that will itself become the logical factors (Pilgrim, Rogers, & Bentall, 2009; Shedler,
agent of change” (p. 34). Ideally, therapeutic relationships 2010). Focusing on enhancing the number and quality
then serve as bridges that enable patients to enhance life of clients’ relationships clearly warrants a central place in
relationships with family, friends, and community. mental health care.
The need may be greater than ever, because social isolation Recreation and Enjoyable Activities
may be increasing, and exacting significant individual and
social costs. For example, considerable evidence suggests Through experiences of positive emotions people transform
that, compared to previous decades, Americans are now themselves, becoming more creative, knowledgeable, resil-
spending less time with family and friends, have fewer in- ient, socially integrated, and healthy individuals
timate friends and confidants, and are less socially involved —Barbara Fredrickson (2002, p. 123).
in civic groups and communities (McPherson, Smith- Involvement in enjoyable activities is central to healthy
Lovin & Brashears, 2006; Putnam, 1995; 2000). However, lifestyles, and the word “re-creation” summarizes some of
there is debate over, for example, whether Internet social the many benefits (Fredrickson, 2002). Behaviorally, many
networking exacerbates or compensates for reduced direct people in psychological distress suffer from low reinforce-
interpersonal contact, and over the methodology of some ment rates, and recreation increases reinforcement. Recre-
social surveys (Fischer, 2009). Yet there is also widespread ation may overlap with, and therefore confer the benefits
agreement that “the health risk of social isolation is com- of, other TLCs such as exercise, time in nature, and social
parable to the risks of smoking, high blood pressure and interaction. Recreation can involve play and playfulness,
obesity…. [while] participation in group life can be like an which appear to reduce defensiveness, enhance wellbeing,
inoculation against threats to mental and physical health” and to foster social skills and maturation in children (Les-
(Jetten et al., 2009, p. 29, 33). ter & Russell, 2008), and perhaps also in adults (Gordon
Beyond the individual physical and mental health costs of & Esbjorn-Hargens, 2007). Recreation can also involve
greater social isolation are public health costs. In “perhaps humor, which appears to mitigate stress, enhance mood,
the most discussed social science article of the 20th cen- support immune function and healing, and serve as a ma-
tury” (Montanye, 2001), and in a subsequent widely read ture defense mechanism (Lefcourt, 2002).
book, Bowling Alone, the political scientist Robert Putnam Further recreational activities include art and other esthetic
(1995; 2000) focused on the importance of “social capi- pleasures, which have long been employed for self-healing.
tal.” Social capital is the sum benefit of the community For example, the great 19th century philosopher, John
Stuart Mill—one of history’s outstanding intellectual

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prodigies—spent his childhood force-feeding himself with controlled trials of tai chi’s effects on psychosocial wellbe-
facts. However, when at twenty he fell into a severe depres- ing found significant benefits for the treatment of anxiety
sion, he turned to the arts—music, painting, and especially and depression, but also noted the mixed quality of the
poetry—for self-therapy and these, his biographer reports, trials (Wang et al., 2009).
“saved him” (Gopnik, 2008). Western self-management skills include mental approaches
Many studies suggest that enjoyable recreational activi- such as self-hypnosis and guided imagery (Trakhtenberg,
ties, and the positive emotions that ensue, foster multiple 2008), as well as somatic approaches, especially muscle
psychological and physical benefits (Ho et al., 2003; relaxation therapies which center on systematically tight-
Gordon & Esbjorn-Hargens, 2007; Lester & Russell, ening and relaxing major muscle groups. By doing this,
2008). However, some studies of recreation include and patients learn to identify and release muscle tension, and
conflate additional healthy lifestyle factors such as exercise, eventually to self-regulate both muscle and psychological
relaxation, and nature, and there are few clinical guidelines. tensions. Muscle relaxation skills are widely used for the
Mental health professionals will therefore need to use their treatment of anxiety disorders, including panic and gener-
clinical skills to assess and support individual patients’ alized anxiety disorders, and meta-analyses reveal medium
interests. “The bottom line message is that we should work to large effect sizes (Manzoni, Pagnini, Castelnuovo, &
to cultivate positive emotions in ourselves and in those Molinari, 2008)
around us not just as end states in themselves, but also as Contemplative skills such as meditation and yoga are
a means of achieving psychological growth and improved now practiced by millions of people in the United States,
psychological and physical health over time” (Fredrickson, and by hundreds of millions worldwide (Walsh, in press).
2002, p. 120). Concomitantly, an explosion of meditation research
has demonstrated a wider array of effects—psychologi-
Relaxation and Stress Management
cal, therapeutic, neural, physiological, biochemical and
Chronic stressors can exact a major toll across multiple or- chromosomal—than any other psychotherapy (Walsh &
gan systems and levels. This toll extends from psychologi- Shapiro, 2006; Walsh, in press).
cal to physiological to chemical (e.g., oxidative stress) to Considerable research suggests that meditation can amelio-
genomic expression (hence the new field of “psychosocial rate a wide array of (especially stress related) psychological
genomics”) (Dusek et al., 2008). Even though stress is uni- and psychosomatic disorders in both adults and children
versal, few people are trained in managing it. In addition, (Arias, Steinberg, Banga & Trestman, 2006; Black, Milam
humans now face an array of novel stressors for which there & Sussman, 2009; Chiesa, 2009; Dusek et al., 2008). Mul-
are no evolutionary or historical precedents. Many people, tiple studies including meta-analyses, show that meditation
therefore, respond unskillfully or even self-destructively, can reduce stress measures in both clinical and normal
aided and abetted by pervasive unhealthy influences such populations (Chiesa & Serreti, 2009; Hofmann, Sawyer,
as advertising, media role models, and novel psychoac- Witt & Oh, 2010). Partially responsive psychosomatic
tive drugs (Buss, 2000). Yet many skillful strategies for disorders include, for example, cardiovascular hyperten-
stress management are now available, ranging from life- sion and hypercholesterolemia, hormonal disorders such
style changes to psychotherapy to self-management skills. as primary dysmenorrheal and type two diabetes, asthma
Beneficial TLCs include almost all those discussed in this and chronic pain (Anderson, Liu & Kryscio, 2008; Shapiro
article—especially exercise, recreation, relationships, and & Carlson, 2009). Responsive psychological difficulties
religious/spiritual involvement—and specific self-manage- include, among others, insomnia, anxiety, depressive eat-
ment skills can both complement and foster TLCs. ing, and borderline personality disorders (Didonna, 2009;
Shapiro & Carlson, 2009).
Self-Management Skills
Meditation can also be beneficial when combined with
Specific stress management skills include somatic, psycho- other therapies. The best known combinations are Dia-
logical, and contemplative approaches. Somatic skills span lectical Behavior Therapy (primarily used for borderline
both ancient Oriental and contemporary Western tech- personality disorder), Mindfulness-Based Stress Reduction,
niques. The Chinese mindful movement practices of tai and Mindfulness-Based Cognitive Therapy. A meta-analysis
chi and qui gong are increasingly popular in the West, and of mindfulness based therapies found large effect sizes for
research studies suggest both physical and psychological anxiety and depressive symptoms of 0.95 and 0.97 respec-
benefits (Kuramoto, 2006). A review of fifteen randomized

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tively, and therapeutic gains were maintained at follow-up mental health. The most massive review to date found
(Hofmann, Sawyer, Witt & Oh, 2010). statistically significant positive associations in 476 of 724
It is now clear that meditation, either alone or in combina- quantitative studies (Koenig, McCullough, & Larson,
tion with other therapies, can be beneficial for both normal 2001). In general, religious-spiritual involvement is most
and multiple clinical populations. However, it is less clear likely to benefit when it centers on themes such as love and
how different meditation practices compare, or how medi- forgiveness, and likely to be less helpful or even harmful
tation compares with other therapies and self-regulation to mental health when themes of punishment and guilt
strategies such as relaxation, feedback, and self-hypnosis predominate.
(Walsh & Shapiro, 2006). Benefits span an array of health measures. Mental health
Yoga may also be helpful for stress and mood disorders. benefits include enhanced psychological, relational, and
However, studies are fewer, and reviews draw cautious con- marital wellbeing, as well as reduced rates of disorders such
clusions (da Silva, Ravindran, & Ravindran, 2009; Kirk- as anxiety, depression, substance abuse, and suicide. For
wood, Rampes, Tuffrey, Richardson, & Pilkington, 2005; physical health, religious involvement seems beneficially re-
Pilkington, Kirkwood, Rampes, & Richardson, 2005). lated to both specific disorders such as hypertension and to
nonspecific mortality rates (Koenig et al., 2001). Strikingly,
In addition to its benefits for relaxation and stress manage- those who attend religious services at least weekly, tend to
ment, meditation may also enhance measures of psycho- survive for approximately seven years longer than those who
logical capacities, health, and maturity in both patients and don’t, even when studies control for factors such as baseline
normals (Walsh & Shapiro, 2006). Particularly important health and health behaviors (Koenig et al., 2001). Impor-
to health care professionals are findings that meditation tant mediating and contributory factors likely include ser-
can enhance valued caregiver qualities such as empathy, vice to others, and especially social support. Contemplative
sensitivity, emotional stability, and psychological maturity, practices such as meditation offer further psychological,
while reducing distress and burnout (Shapiro & Carlson, somatic, and spiritual benefits (Didonna, 2009; Shapiro &
2009). On the cognitive side, studies suggest that medita- Carlson, 2009; Walsh & Shapiro, 2006).
tion can enhance some measures of cognition, and may
reduce age-related cognitive losses and corresponding brain Religion, Spirituality, and Psychological Development
shrinkage (Pagnoni & Cekic, 2007; Xiong & Doraiswamy,
2009). The universality of stress, as well as the multiple It is important for mental health professionals to recognize
benefits of both lifestyle changes and self-regulation skills that there are multiple levels of religious development.
for managing stress, suggests that these TLCs and self- These levels range from preconventional to conventional
regulation skills deserve to be central components of health to postconventional (or from prepersonal to personal, and
professionals’ training, personal and professional practice, transpersonal), and are associated with extremely different
and public outreach. kinds of religious faith, practice, behavior, and institutions
(Fowler, 1995; Wilber, 2005, 2006).
Religious and Spiritual Involvement For example, consider the developmental stages of reli-
Religious and spiritual concerns are vitally important to gious faith. At the preconventional level, mythic-literal
most people and most patients. Some 90% of the world’s faith involves an unreflective, literal acceptance of cultur-
population engages in religious or spiritual practices, these ally provided beliefs. At the synthetic-conventional level,
practices are a major means of coping with stress and people begin to create their own individual, but still largely
illness, and most patients say that they would welcome unreflective, synthesis of diverse conventional beliefs.
their health professionals inquiring about religious issues At later postconventional stages, such as conjunctive and
(Koenig, 2002). Yet few health professionals do. This may universalizing faith, individuals critically reflect on conven-
be unfortunate given the prevalence and importance of tional assumptions, open to multiple perspectives, confront
religious-spiritual practices, their many influences on life- paradoxes, and extend their care and concern to all peoples
style and health, their impact on therapeutic relationships (Fowler, 1995; Wilber, 2006).
and effectiveness, and the deep existential issues they open When developmental differences go unrecognized, prob-
(Fowler, 1995; Koenig, 2009). lems ensue. For example, the views of one level are taken
Considerable research suggests a complex but usually as normative, and those at this level tend to assume that
beneficial relationship between religious involvement and people at other levels are mistaken, misguided, malevolent,

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or disturbed (Wilber, 2005). Many contemporary religious priate, to inquire about and support healthy involvement.
and cultural conflicts appear to reflect these kinds of cross-
level misunderstandings (Walsh, 2009). Contribution and Service
This developmental perspective brings new clarity to many From ancient times, service and contribution to others
religious and spiritual issues. For example, it makes clear have been regarded as virtues that can benefit both giver
that religions are not only culturally diverse, but also de- and receiver (Walsh, 1999). The world’s major spiritual
velopmentally diverse, and that mental health professionals traditions emphasize that, when viewed correctly, service
need to be sensitive to both kinds of diversity. Religion can is not necessarily a sacrifice, but rather can foster qualities
be an expression of immaturity, conventional maturity, and that serve the giver, such as happiness, mental health, and
postconventional maturity, and of corresponding motives spiritual maturity. Altruism is said to reduce unhealthy
and concerns ranging from egocentric to ethnocentric to mental qualities such as greed, jealousy, and egocentricity,
worldcentric (Wilber, 2006). Interpretations that view while enhancing healthy qualities such as love, joy, and
religion as, for example, always regressive or always tran- generosity (Hopkins, 2001; Walsh, 1999). The benefits of
scendental, invariably overlook this developmental perspec- service are also said to extend to healing, such that heal-
tive. Examples of reductionistic interpretations that view ing oneself and others can be intimately linked. Multiple
religion as necessarily regressive or pathological include the myths and healing traditions describe “wounded healers”:
writings of the so called “neoatheists,” such as the recent people who by virtue of their own illness learn to heal oth-
extremely popular books The God Delusion, The End of ers, and may thereby be healed themselves.
Faith, and God Is Not Great, all of which are ignorant of In our own time, both theory and research point to cor-
developmental research (Dawkins, 2006; Harris, 2005; relations between altruism and measures of psychological
Hitchens, 2007). Unfortunately, the widespread failure to and physical health. Multiple studies, including those that
recognize developmental differences—in faith, morality, control for prior health factors, suggest that people who
values, ego, worldview, and more—and their far reaching volunteer more are psychologically happier and healthier,
implications for religion and multiple other areas of life, physically healthier, and may even live longer (Borgonovi,
seems a significant factor underlying many contemporary 2009; Grimm, Spring, & Dietz, 2007; Post, 2007). The so
cultural conflicts (Walsh, 2009; Wilber, 2006) called “paradox of happiness” is that spending one’s time
Of course, religious behavior can sometimes be regressive and resources on others can make one happier (Walsh,
or pathological. However, religious behavior can also both 1999).
express and foster healthy, mature, and even exception- Altruists of all ages may experience a “helpers-high” (Post,
ally mature development. In fact, a classic goal of spiritual Underwood, Schloss, & Hulbert, 2002). Even required
practices such as meditation is to foster postconventional community service for adolescents seems to effect long-
development through, for example, bhavana (mental cul- term positive psychological changes, while even mandated
tivation) in Buddhism and lien-hsin (refining the mind) in monetary donations can make college students happier
Taoism (Walsh & Shapiro, 2006). Contemporary research than spending the money on themselves (Dunn, Aknin,
and meta-analysis are supportive, since meditators tend & Norton, 2009). Erik Erikson (1959) famously sug-
to score higher on measures of ego, moral and cognitive gested that “generativity” (care and concern for others,
development, as well as self-actualization, coping skills and and especially for future generations) may be a hallmark
defenses, and states and stages of consciousness (Alexan- of successful maturation. Moreover, altruism has a positive
der & Langer, 1990; Alexander, Rainforth, & Gelderloos, social contagion or multiplier effect. For example, coopera-
1991). Ideally, religious-spiritual traditions offer both tive behaviors cascade through social networks to induce
“legitimacy” (support for people’s current level of psycho- further cooperation in others (Fowler & Christakis, 2010),
logical and faith development), as well as “authenticity” while at the community level, service is a key contributor
(support for maturation beyond current levels) (Wilber, to social capital (Putnam, 2000).
2005). Given the significance of religious and spiritual in-
volvement, it seems important for therapists to be familiar In summary, considerable research shows positive relation-
with developmental and other key issues, and where appro- ships between altruistic behavior and multiple measures
of psychological, physical, and social wellbeing. However,
there are important qualifiers. Major exceptions include
“caretaker burnout,” such as overwhelmed family members
caring for a demented spouse or parent. Furthermore, the

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kind of motivation powering prosocial behavior affects out- logical, environmental, and lifestyle changes accelerate.
come. Whereas service motivated by pleasure in helping is
associated with multiple positive measures (such as positive Interactions Among Therapeutic Lifestyle Factors
affect, self-esteem, self-actualization, and life satisfaction), Fortunately, individual TLCs appear to counter many
this may not be true when service is driven by a sense of medical and psychological complications of contempo-
internal pressure, duty, and obligation (Gebauer, Riketta, rary pathogenic lifestyles. This raises a hopeful possibility:
Broemer, & Mai, 2008). Might multiple TLCs be even more effective? There is evi-
Psychotherapists repeatedly rediscover the healing po- dence for this in both animal studies and clinical medicine.
tentials of altruistic behavior for both their patients and For example, physical activity increases neuronogenesis in
themselves. Alfred Adler emphasized the benefits of “social the rat hippocampus. However, the effect is maximal only
interest,” while helping other members contributes to the when the animals are exposed to a rich social environ-
effectiveness of group therapy and support groups such as ment rather than living in isolation (Stranahan, Khalil &
Alcoholics Anonymous (Duncan et al., 2010). Likewise, Gould, 2006). Similarly, in his program to reverse coro-
therapists often report that helping their patients can nary arteriosclerosis, Dean Ornish employed four TLCs:
enhance their own wellbeing (Yalom, 2002). Wisely per- exercise, vegetarian diet, relaxation and stress management,
ceived, altruism is not self-sacrifice, but rather enlightened and social support. Each proved beneficial, and effects were
self-interest (Walsh, 1999). As the Dalai Lama put it, “if additive (Pischke et al., 2008). Might this also be true for
you’re going to be selfish, be wisely selfish—which means psychological disorders? Quite possibly, but as yet we have
to love and serve others, since love and service to others no clear answer.
bring rewards to oneself that otherwise would be unachiev-
able” (Hopkins, 2001, p.150). Difficulties of Implementing Therapeutic Lifestyles
These benefits of altruism hold major implications for our Given the many advantages of TLCs, why have mental
understanding of health, lifestyle, and therapy. Based on health professionals been so slow to adopt them? The
their findings, Brown et al. (2003) wrote an article titled reasons range from patients to therapists to society. Effec-
“Providing Social Support May be More Beneficial Than tive public health programs will therefore need to address
Receiving It,” and concluded that interventions “designed all these.
to help people feel supported may need to be redesigned For patients, TLCs can require considerable and sus-
so that the emphasis is on what people do to help others” tained effort, and many patients feel unable or unwilling
(p. 326). Other researchers quipped, “If giving weren’t free, to do them. Patients often have little social support, little
pharmaceutical companies could herald the discoveries understanding of causal lifestyle factors, and a passive
of a stupendous new drug called ‘Give Back’—instead of expectation that healing comes from an outside authority
‘Prozac’…” (Post & Niemark, 2007 p. 7). Contribution or pill (Duncan et al., 2010). Societally, whole industries
and service to others have long been considered central ele- are geared towards encouraging unhealthy choices. Patients
ments of a life well lived. Now they can also be considered contend with a daily barrage of psychologically sophisti-
central elements of a healthy life. cated advertisements encouraging them, for example, to
consume alcohol, nicotine, and fast food, in the never end-
Discussion ing search for what the food industry calls the “bliss point”
A culture’s technology has far reaching effects on people’s of “eatertainment” through “hypereating”(Kessler, 2009).
psychology and lifestyles (Wilber, 2000), and modern tech- Unfortunately, you can never get enough of what you don’t
nology is now affecting our psychology, biology, society, really want, but you can certainly ruin your health and life
and lifestyles in ways we are only beginning to compre- trying (Walsh, 1999).
hend. Moreover, technological innovations and their life- Therapists also face challenges. The first is simply to
style effects are changing “more quickly than we know how become familiar with the large literature on TLCs. The
to change ourselves” (Putnam, 2000, p. 402). Many of the second is a professional bias towards pharmacological
resultant costs are doubtless as yet unrecognized, and this and formal psychotherapeutic interventions. In addition,
raises a disconcerting question: Could some of our patients fostering patients’ TLCs can be time intensive, can demand
be “canaries in the mine,” warning us of ways of life that considerable therapeutic skill, and is not well reimbursed.
may exact a toll on us all? This is a question that health Therapists may also harbor negative expectations (not with-
professionals will need to confront increasingly as techno-

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out some justification) that patients won’t maintain the contemporary lifestyles, such interventions may be essen-
necessary changes. However, it is crucial to be aware of the tial. In the 21st century, therapeutic lifestyles may need to
Rosenthal effect: the self-fulfilling power of interpersonal be a central focus of mental, medical, and public health.
expectations. Finally, cognitive dissonance may be at work
when therapists’ own lifestyles are unhealthy (McEntee & References
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Lifestyle and Mental Health

Roger Walsh, M.D., Ph.D.

Lifestyle and Mental Health

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