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Wellness Series Part 3 – Sweat It Off: The Importance of Physical Activity in Client Biopsychosocial Functioning

 

Physical activity is beneficial for many of our clients’ presenting problems, including mood disorders, cognitive and emotional functioning, and even social relationships (e.g., Biddel & Asare, 2011; Mikkelsen, Stojanovska, Polenakovic, Bosevski, & Apostolopoulos, 2017; Johnson et al., 2018; Yorgason, Johnson, Hill, & Selland, 2018). However, only 25% adults in the United States meet the recommended guidelines for physical activity (Centers for Disease Control & Prevention [CDC], 2019), suggesting that our clients’ biopsychosocial functioning may be less than ideal.


In addition, research has found that physical activity in addition to therapy has better outcomes when compared to only talk therapy (Jacquart et al., 2014; Stathopoulou, Powers, Berry, Smits, & Otto, 2006)—strengthening the case for mental and behavioral health providers to include physical activity as part of therapy. Importantly, marriage and family therapists (MFTs) are ideally poised to assess and intervene in physical activity from a systemic perspective. Unfortunately, MFTs receive very little guidance and training on how to incorporate it into treatment. Perhaps many therapists do not know where to start, worry about overstepping the scope of practice, think they may not have influence in a domain outside of therapy, or may not know all the important cognitive, emotional, and social implications of physical activity and how to best convey them to clients. To that end, the following article presents the 5-A model to guide MFTs in therapy and covers relevant information for how to assess, discuss, and integrate physical activity into treatment.

When might physical activity be important to bring into therapy?

Although physical activity can be helpful to all clients regardless of their presenting issue, there are a few indications where assessment and integration of physical activity in treatment may take precedence. Indications of when to consider physical activity include: 1) ADHD, 2) stress and anxiety symptoms, 3) depressive symptoms, 4) addiction, and 5) relational conflict, including parent-child difficulties and romantic partner conflict. See Novak and Ellis (2021) for more detailed information. Notably, however, MFTs must be sensitive to the following considerations and refer to additional reading and training on the following topics when considering physical activity in treatment: 1) weight bias and discrimination (Cravens, Pratt, Palmer, & Aamar, 2016), 2) cultural sensitivity (McDowell, Knudson-Martin, & Bermudez, 2017), and 3) considerations for eating disorders (DeJesse & Zelman, 2013) and trauma (Rosenbaum et al., 2015).

ADHD

A hallmark of those clients with ADHD includes a deficit of neurotransmitters thus creating an over or underactive ability to shift attention (Ratey, 2008; Swanson et al., 2007). Physical activity combats many of the issues of ADHD, by raising the baseline levels of important neurotransmitters, growing new receptors in the reward and attention centers (Lin & Kuo, 2013), and improving the functioning of basal ganglia, which is responsible for the shifting of attention (del Campo, Chamberlain, Sahakian, & Robbins, 2011). In intervention studies over 10 weeks, several studies have found evidence for physical activity relieving ADHD symptoms in both children and adults (Archer & Kostrezawa, 2012; Wigal, Emmerson, Gehricke, & Galassetti, 2013).

Stress and anxiety

Chronic stress has severe damaging effects on the brain, including (among many other effects) the constant release of the stress hormone cortisol, the pruning and shrinkage of the hippocampus, and stronger wired connections in the amygdala—resulting in a lower trigger point of stress and reduced ability to cope with stress (Ratey, 2008). Chronic stress can often develop into an anxiety disorder. Physical activity helps to combat, reduce, and repair the brain mechanisms involved in both stress and anxiety. See DeBoer, Powers, Utschig, Otto, and Smits (2012) for a review of physical activity in the treatment of anxiety.

Depressive symptoms

There are several important mechanisms worth mentioning in which physical activity can influence depression and depressive symptoms (see Cooney et al. [2014] for a meta-analysis), including the systematic boosting of norepinephrine, dopamine, and serotonin (Lin & Kuo, 2013), all three of which can improve self-esteem, happiness, motivation, and contentment. Physical activity also improves the connectivity of the brain through synaptogenesis (making new connections), and neurogenesis (growing new neurons). Finally, physical activity releases endorphins, which dull pain and produce euphoria—important for clients with depression (Ratey, 2008).

Addiction

Physical activity has important implications for combating and managing a range of addictive behaviors—including alcohol and substance use disorder (Ratey, 2008), especially by combating the mood and stress-related mechanisms involved and discussed above. In the brain, it boosts neurotransmitters, increases neurogenesis, and synaptogenesis (especially in the hippocampus which are decreased and hampered by addiction), reprograms the basal ganglia, and releases endocannabinoids (Lin & Kuo, 2013; Ratey, 2008). Behaviorally, it dampens cravings, reduces impulsivity, and provides pleasurable states and positive alternative activities (e.g., Ashdown-Franks et al., 2020). Importantly, research indicates exercise combined with substance use programs are more effective than only substance abuse treatment programs and has shown significant changes for up to 18 months (Ashdown-Franks et al., 2020; Stathopoulou et al., 2006).

Relational conflict

For both romantic partner and parent-child dyads, conflict and conflict cycles can increase the likelihood of reacting rather than responding, whereby the individual’s biology (amygdala and limbic brain) hijacks their ability to reason and regulate (the prefrontal cortex). Thus, in conflict, individuals can enter in the flight-fight-freeze responses and leave their window of tolerance (Siegel, 1999). Physical activity can improve heart rate variability (HRV), which is the relative balance between the sympathetic nervous systems (SNS; the “accelerator”—hyperarousal; chaos, fighting, anger, etc.) and the parasympathetic nervous system (PNS; the “brake”—hypoarousal: shutdown, withdrawn, flight or freeze) SNS and PNS (Porges, 2011). Thus, essentially, physical activity is one of the best methods to widen the window of tolerance for stress and dysregulation, improving clients’ ability to stay calm, regulate, and maintain themselves in spite of conflict.

Implications and recommendations

The 5-A model (Beaulac, Carlson, & Boyd, 2011; Whitlock, Orleans, Pender, & Allan, 2002) is a particularly helpful framework for family therapists and is based on recommendations from other mental health professions and behavioral care fields. It includes five domains: 1) Assess, 2) Advise, 3) Agree, 4) Assist, and 5) Arrange.

1: Assess physical activity levels, health risks, abilities, and readiness to change

A proper assessment should be conducted with clients focusing on physical health status and conditions, the presence of functional disabilities or limitations, past and current physical health levels, family medical background and history, physical proximity to structured and unstructured locations (access to gyms, health clubs, walking trails, etc.), current knowledge of physical activity for the brain, and any underlying heart (tachycardia or arrhythmias, blockages, stint placements, etc.), lung (e.g., chronic obstructive pulmonary disease [COPD]), or brain (aneurysms) conditions, among many other factors (e.g., Ashe & Khan, 2004). An in-session interview assessment should assess both first and second order changes related to physical activity (Novak & Ellis, 2021). Finally, therapists can assess for HRV and physical activity levels via smartphones and heart rate monitors if wanting a more objective measure of physical activity and emotion regulation/stress responses.

2: Advise on emotional, cognitive, and relationship benefits

MFTs should emphasize information about physical activity for the brain, mental health, and relationships, instead of the view of physical activity as important for shape, size, or weight, and only think of a number on a scale. Please refer to the supplemental files in Novak & Ellis (2021) for sample scripts to use in therapy with clients. Importantly, not all exercise is equal in achieving the benefits described earlier. Most of the important brain benefits occur between 55 and 90 percent of the maximum target heart rate. Maximum heart rate calculation is 220 minus age (e.g., 220–30 = 190 max heart rate; 55% of max: 190 × .55 = 104.5; 90% of max: 190 × .90 = 171). Between 55% and 65%, serotonin and brain-derived neurotrophic factor (BDNF) is released, between 65% and 75% cell repair and cleaning/recycling takes place, and between 75% and 90% endorphins and endocannabinoids are released. Research has shown that at least 20 minutes within these thresholds for three times per week is optimal for brain health (Ratey, 2008). The MFT could also provide psychoeducation about recommended frequency and intensity of workouts for optimal brain health and recommend they discuss interval training (includes a mix of moderate and high-intensity training) with their healthcare provider and/or exercise specialist.

3: Agree on goals and develop an action plan

Before beginning an exercise program or increasing their physical activity, clients should have authorization (via release of information) from their primary care physician or family practitioner. In cases in which the client does not have health insurance or a healthcare provider, the therapist may consider having the client sign a waiver or form to participate in exercise or consider having a document with language about the risks of an exercise program without physician consent. Next, therapists should work within the confines, constraints, and possibilities of the client’s situation and help clients come up with goals that are specific, measurable, attainable, relevant, and time-related (known as S.M.A.R.T. Goals; Doran, 1981).

4: Assist in overcoming barriers and linking with social and community resources

Many common barriers include low-self efficacy, fatigue, fear, lack of money or time, lack of knowledge, and other structural and practical reasons (e.g., Qui, Sun, Cai, Liu, & Yang, 2012; Venditti et al, 2014). In addition, social relationships can facilitate or hamper engagement in exercise. MFTs should assess for the degree to which social relationships can impede engagement or maintenance in exercise habits, but also the degree to which they can help with accountability, support, and joint exercise behaviors. Finally, local community resources should be explored, included, and discussed as part of a well-balanced treatment plan.

5: Arrange for follow-up assessment, feedback, and support

The family therapist could do brief check-ins at the beginning of the session or use behavioral charting or tracking. Many apps exist that can track physical activity and movement and have been shown to improve physical activity levels. The therapist should also collaborate and refer to a personal trainer or other medical providers who can properly help address barriers to long-term maintenance.

The 5-A model is a particularly helpful framework for family therapists and is based on recommendations from other mental health professions and behavioral care fields. 

Concluding thoughts on therapy practice

It is important to consider the real-world implications of a focus on physical activity in treatment. Many of the studies reviewed suggest that although there are immediate and important physiological changes and benefits to physical activity, improvement for major mental health disorders occur after at least 8-10 weeks for consistent and sustained changes (Jacquart et al., 2014). In addition, once an initial discussion and session is focused on the psychophysiological and social benefits, as well as setting goals, the therapist may only routinely check up on physical activity levels in the first few minutes of therapy unless there are more barriers or concerns to address. To that end, using behavioral tracking or charts may be helpful to review before moving on to therapy as usual. As always, therapists should pay close attention to a client’s physical activity levels and how it may be impacted by or impact their livelihood, sociocultural context, and overall physical health and respond as necessary.

While these above recommendations and the implications of physical activity have yet to be examined in therapy, they nonetheless highlight an important area of competency for MFTs. We, as MFTs, can have quite an influence in the ‘extratherapeutic factors’ that play a large role in client functioning. Further, as systemic thinkers and practitioners, we can help clients understand the role exercise can have in multiple domains of life, overcome systemic barriers, and facilitate change in the whole family system. Thus, MFTs are ideal providers to create long-lasting change in physical activity levels.

We, as MFTs, can have quite an influence in the ‘extratherapeutic factors’ that play a large role in client functioning.

Josh R. Novak, PhD, LMFT-S, is an AAMFT Professional Member and holds the Clinical Fellow designation. He currently serves as an assistant professor in the MFT program at Auburn University. He is the director the Relationships & Health Lab, an interdisciplinary collaborative team of faculty and students across many fields, including Dietetics/Nutrition, Sleep Science, Kinesiology, Nursing, Pharmacy, Psychology, and Human Development and Family Science. His program of research focuses on the nexus of relationships and health, within and across disease contexts, and how partners and families influence health and health behaviors.


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