Lifestyle and Mental Health

Lifestyle and Mental Health
Roger Walsh
University of California, Irvine College of Medicine
Mental health professionals have significantly underesti- the diseases exacting the greatest mortality and morbidity—
mated the importance of lifestyle factors (a) as contributors such as cardiovascular disorders, obesity, diabetes, and
to and treatments for multiple psychopathologies, (b) for cancer—are now strongly determined by lifestyle. Differ-
fostering individual and social well-being, and (c) for ences in just four lifestyle factors—smoking, physical ac-
pre.ierving and optimizing cognitive function. Conse- tivity, alcohol intake, and diet—exert a major impact on
quently, therapeutic lifestyle changes (TLCs) are underuti- mortality, and "even small differences in lifestyle can make
lized despite considerable evidence of their effectiveness in a major difference in health status" (Khaw et al., 2008, p.
both clinical and normal populations. TLCs are sometimes 376).
as effective as either psychotherapy or pharmacotherapy TLCs can be potent. They can ameliorate prostate
and can offer significant therapeutic advantages. Important cancer, reverse coronary arteriosclerosis, and be as effec-
TLCs include exercise, nutrition and diet, time in nature, tive as psychotherapy or medication for treating some
relationships, recreation, relaxation and stress manage-
depressive disorders (Frattaroli et al., 2008; Pischke, Scher-
ment, religious or spiritual involvement, and service to
witz, Weidner & Omish, 2008; Sidhu, Vandana, & Balon,
others. This article reviews research on their effects and
2009). Consequently, there is growing awareness that con-
effectiveness; the principles, advantages, and challenges
temporary medicine needs to focus on lifestyle changes for
involved in implementing them; and the forces (economic,
primary prevention, for secondary intervention, and to em-
institutional, and professional) hindering their use. Where
possible, therapeutic recommendations are distilled into power patients' self-management of their own health.
easily communicable principles, because such ease of com- Mental health professionals and their patients have
munication strongly infiuences whether therapists recom- much to gain from similar shifts. Yet TLCs are insuffi-
mend and patients adopt interventions. Finally, the article ciently appreciated, taught, or utilized. In fact, in some
explores the many implications of contemporary lifestyles ways, mental health professionals have moved away from
and TLCs for individuals, society, and health professionals. effective lifestyle interventions. Economic and institutional
In the 21st century, therapeutic lifestyles may need to be a pressures are pushing therapists of all persuasions toward
central focus of mental, medical, and public health. briefer, more stylized interventions. Psychiatrists in partic-
ular are being pressured to offer less psychotherapy, pre-
Keywords: lifestyle, therapeutic lifestyle changes, mental scribe more drugs, and focus on 15-minute "med checks,"
health, psychopathology, cognitive capacities a pressure that psychologists who obtain prescription priv-
T
ileges will doubtless also face (Mojtabai & Olfson, 2008).
he central thesis of this euticle is very simple: Health As a result, patients suffer from inattention to complex
professionals have significantly underestimated the psychodynamic and social factors, and therapists can suffer
importance of lifestyle for mental health. More spe- painful cognitive dissonance and role strain when they
cifically, mental health professionals have underestimated shortchange patients who need more than what is allowed
the importance of unhealthy lifestyle factors in contributing by mandated brief treatments (Luhrmann, 2001).
to multiple psychopathologies, as well as the importance of
healthy lifestyles for treating multiple psychopathologies, A further cost of current therapeutic trends is the
for fostering psychological and social well-being, and for underestimation and underutilization of lifestyle treatments
preserving and optimizing cognitive capacities and neural (Angelí, 2009) despite considerable evidence of their ef-
functions. fectiveness. In fact, the need for lifestyle treatments is
Greater awareness of lifestyle factors offers major growing, because unhealthy behaviors such as overeating
advantages, yet few health professionals are likely to mas- and lack of exercise are increasing to such an extent that the
ter the multiple burgeoning literatures. This article there- World Health Organization (2008, para. 1 ) warned that "an
fore reviews research on the effects and effectiveness of escalating global epidemic of overweight and obesity—
eight major therapeutic lifestyle changes (TLCs); the prin- 'globesity'—is taking over many parts of the world" and
ciples, advantages, and challenges involved in implement-
ing them; the factors hindering their use; and the many
implications of contemporary lifestyles for both individuals This article was published Online First January 17. 2011.
Correspondence conceming this article should be addressed to Roger
and society. Walsh, Department of Psychiatry and Human Behavior. University of
Lifestyle factors can be potent in determining both Califomia College of Medicine, Irvine, CA 92697-1675. E-mail:
physical and mental health. In modem affluent societies. rwalsh@uci.edu
October 2011 • American Psychologist 579

© 2011 American Psychological Association 0003-066X/11/$12.00
Vol. 66. No. 7. .S79-592 [X)t: IO.I037/a0021769
tion can be therapeutic for multiple psychological and
psychosomatic disorders (Chiesa, 2009; Didonna, 2009;
Shapiro & Carlson, 2009). Yet it can also enhance psycho-
logical well-being and maturity in normal populations and
can be used to cultivate qualities that are of particular value
to clinicians, such as calmness, empathy, and self-actual-
ization (Shapiro & Carlson, 2009; Walsh, 2011; Walsh &
Shapiro, 2006).
Knowledge of TLCs can benefit clinicians in several
ways. Utilizing TLCs may result in greater clinical flexi-
bility and effectiveness and less role strain. It will be
particularly interesting to see the extent to which clinicians
exposed to information about TLCs adopt healthier life-
styles themselves and, if so, how adopting them affects
their professional practice, because there is already evi-
dence that therapists with healthy lifestyles are more likely
to suggest lifestyle changes to their patients (McEntee &
Halgin, 1996). There are also entrepreneurial opportunities.
Clinics are needed that offer systematic lifestyle programs
for mental health that are similar to current programs for
reversing coronary artery disease (Pischke et al., 2008).
Roger Walsh For societies, TLCs may offer significant community
and economic advantages. Economic benefits can accrue
from reducing the costs of lifestyle-related disorders such
as obesity, which alone accounts for over $100 billion in
exacting enormous medical, psychological, social, and eco- costs in the United States each year (World Health Orga-
nomic costs.
nization, 2008). Community benefits can occur both di-
Advantages of Therapeutic Lifestyle rectly through enhanced personal relationships and service
Changes (Post, 2007) and indirectly through social networks.
Recent research demonstrates that healthy behaviors
Lifestyle changes can offer significant therapeutic advan- and happiness can spread extensively through social net-
tages for patients, therapists, and societies. First, TLCs can works, even through three degrees of separation to, for
be both effective and cost-effective, and some—such as example, the friends of one's friends' friends (J. H. Fowler
exercise for depression and the use of fish oils to prevent & Christakis, 2008, 2010). Encouraging TLCs in patients
psychosis in high-risk youth—may be as effective as phar- may therefore inspire similar healthy behaviors and greater
macotherapy or psychotherapy (Amminger et al., 2010; well-being in their families, friends, and co-workers and
Dowd, Vickers, & Krahn, 2004; Sidhu et al., 2009). TLCs thereby have far-reaching multiplier effects (Christakis,
can be used alone or adjunctively and are often accessible 2009; J. H. Fowler & Christakis, 2010). These effects offer
and affordable; many can be introduced quickly, some- novel evidence for the public health benefits of mental
times even in the first session (McMorris, Tomporowski & health interventions in general and of TLCs in particular.
Audiffren, 2009). So what lifestyle changes warrant consideration? Con-
TLCs have few negatives. Unlike both psychotherapy siderable research and clinical evidence support the follow-
and pharmacotherapy, they are free of stigma and can even ing eight TLCs: exercise, nutrition and diet, time in nature,
confer social benefits and social esteem (Borgonovi, 2(X)9). relationships, recreation, relaxation and stress manage-
In addition, they have fewer side effects and complications ment, religious and spiritual involvement, and contribution
than medications (Amminger et al., 2010). and service to others.
TLCs offer significant secondary benefits to patients,
such as improvements in physical health, self-esteem, and Exercise
quality of life (Deslandes et al., 2009). Furthermore, some Exercise offers physical benefits that extend over multiple
TLCs—for example, exercise, diet, and meditation—may body systems. It reduces the risk of multiple disorders,
also be neuroprotective and reduce the risk of subsequent including cancer, and is therapeutic for physical disorders
age-related cognitive losses and corresponding neural ranging from cardiovascular diseases to diabetes to prostate
shrinkage (Hamer & Chida, 2009; Pagnoni & Cekic, 2007; cancer (Khaw et al., 2008; Omi.sh et al., 2008). Exercise is
Raji et al., 2010). Many TLCs—such as meditation, relax- also, as the Harvard Mental Health Letter ("Therapeutic
ation, recreation, and time in nature—are enjoyable and Effects," 2000, p. 5) concluded, "a healthful, inexpensive,
may therefore become healthy self-sustaining habits (Di- and insufficiently used treatment for a variety of psychiatric
donna, 2009). disorders."
Many TLCs not only reduce psychopathology but can As with physical effects, exercise offers both preven-
also enhance health and well-being. For example, meditative and therapeutic psychological benefits. In terms of
580 October 2011 • American Psychologist

prevention, both cross-sectional and prospective studies emotional states, and caregiver distress (Christofoletti,
show that exercise can reduce the risk of depression as well Oliani, Gobbi, & Stella, 2007; Deslandes et al., 2009).
as neurodegenerative disorders such as age-related cogni- Meta-analytic studies provide more flne-grained de-
tive decline, Alzheimer's disease, and Parkinson's disease tails about the cognitive benefits of exercise for the elderly
(Hamer & Chida, 2009; Sui et al., 2009). In terms of and offer four kinds of good news. First, the effects can be
therapeutic benefits, responsive disorders include depres- large, reducing the risk of Alzheimer's disease by 45% and
sion, anxiety, eating, addictive, and body dysmorphic dis- increasing cognitive performance by 0.5 SD (Hamer &
orders. Exercise also reduces chronic pain, age-related cog- Chida, 2009). Second, though women may gain more than
nitive decline, the severity of Alzheimer's disease, and men, everyone seems to benefit, including both clinical and
some symptoms of schizophrenia (Colcombe & Kramer, nonclinical populations. Third, improvements extend over
2003; Daley, 2002; Deslandes et al., 2009; Stathopoulou, several kinds of psychological functions, ranging from
Powers, Berry, Smits, & Otto, 2006). processing speed to executive functions. Fourth, executive
The most studied disorder in relation to exercise to functions, such as coordination and planning, appear to
date is mild to moderate depression. Cross-sectional, pro- benefit most, a welcome finding given that executive func-
spective, and meta-analytic studies suggest that exercise is tions are so important, and that both they and the brain
both preventive and therapeutic, and in terms of therapeutic areas that underlie them are particularly age sensitive (Col-
benefits it compares favorably with pharmacotherapy and combe & Kramer, 2003; Erickson & Kramer, 2009).
psychotherapy (Dowd et al., 2004; Sidhu et al., 2009). Both Finally, meta-analyses reveal the specific elements of
aerobic exercise and nonaerobic weight training are effec- exercise that benefit cognition. Relatively short programs
tive for both short-term interventions and long-term main- of one to three months in length offer significant benefits,
tenance, and there appears to be a dose-response relation- though programs of six months or longer are more benefi-
ship, with higher intensity workouts being more effective. cial. There seems to be a threshold effect for session
Exercise is a valuable adjunct to pharmacotherapy, and duration, because sessions shorter than 30 minutes—while
special populations such as postpartum mothers, the el- valuable for physical health—yield minimal cognitive
derly, and perhaps children appear to benefit (Hamer & gains. Cognitive benefits are enhanced by more strenuous
Chida, 2008; Larun, Nordeim, Ekeland, Hagen, & Heian, activity and by combining strength training with aerobics
2006; Sidhu et al., 2009). (Colcombe & Kramer, 2003; Hertzog, Kramer, Wilson, &
Lindenberger, 2009). In short, research validates the words
Possible mediating factors that contribute to these
of the second U.S. president, John Adams, who wrote, "Old
antidepressant effects span physiological, psychological,
minds are like old horses; you must exercise them if you
and neural domains. Proposed physiological mediators in-
wish to keep them in working order" (Hertzog et al., 2()09,
clude changes in serotonin metabolism, improved sleep, as
p. 26).
well as endorphin release and consequent "runner's high"
Fortunately, even brief counseling can motivate many
(Deslandes et al., 2009; Stathopoulou et al., 2006). Psycho- patients to exercise (Long et al., 1996), and the risks are
logical factors include enhanced self-efficacy and self- minimal, although an initial medical exam may be war-
esteem, interruption of negative thoughts and rumination ranted. Yet despite the many mental and medical benefits
(Dowd et al., 2004), and perhaps the breakdown of mus- of exercise, only some 10% of mental health professionals
cular armor, the chronic psychosomatic muscle tension recommend it. And who are these 10%? Not surprisingly,
patterns that express emotional conflicts and are a focus of they are likely to exercise themselves (McEntee & Halgin,
somatic therapies (Smith, 2000). 1996).
Neural factors are especially intriguing. Exercise in-
creases brain volume (both gray and white matter), vascu- Nutrition and Diet
larization, blood flow, and functional measures (Erickson There is now considerable evidence of the importance of
& Kramer, 2009; Hamer & Chida, 2009). Animal studies nutrition for mental health, and an extensive review of over
suggest that exercise-induced changes in the hippocampus 160 studies suggests that dietary factors are so important
include increased neuronogenesis, synaptogenesis, neuro- that the mental health of nations may be linked to them
nal preservation, intemeuronal connections, and BDNF (Gómez-Pinilla, 2008). Given the enonnous literature on
(brain-derived neurotrophic factor, the same neurotrophic this topic, it is easy to feel overwhelmed. Therefore, the
factor that antidepressants upregulate) (Cotman & Berch- following sections review this complex literature but also
told, 2002). distill easily communicable principles, because such ease
Given these neural effects, it is not surprising that of communication strongly influences whether therapists
exercise can also confer significant cognitive beneflts (Mc- recommend and patients adopt such treatments (Duncan,
Morris et al., 2009). These range from enhancing academic Miller, Wampold, & Hubble, 2009). Two major dietary
performance in youth, to aiding stroke recovery, to reduc- components must be considered: food selection and sup-
ing age-related memory loss and the risk of both Alzhei- plements.
mer's and non-Alzheimer's dementia in the elderly (Hamer
& Chida, 2009; Quaney et al, 2009). Multiple studies show
Food Selection
that exercise is a valuable therapy for Alzheimer's patients For food selection, the key principles for TLCs are to
that can improve intellectual capacities, social functions. emphasize a diet that

1. Consists predominantly of multicolored fruits and em diets are often high in omega-6s and deficient in omega-3s
vegetables (a "rainbow diet"). (Freeman et al., 2006).
2. Contains some fish (a "pescovegetarian diet"): Is this dietary deficiency associated with psychopa-
Preference should be given to cold deep-seawater thology? Both epidemiological and clinical evidence sug-
fish (e.g., salmon), which are high in beneficial gest that it is. Affective disorders have been the ones most
omega-3 fish oils, while avoiding the four species closely studied, and epidemiological studies, both within
with high mercury levels (shark, swordfish, king and between countries, suggest that lower flsh consumption
mackerel, and tilefish) (Oken et al., 2008). is associated with significantly, sometimes dramatically,
3. Reduces excessive calories: For societies confront- higher prevalence rates of these disorders (Freeman et al.,
ing the "globesity" epidemic, reducing excess cal- 2006; Noaghiul & Hibbeln, 2003). Likewise, lower omega-3
ories offers both economic and public health ben- levels in tissue are correlated with greater symptom sever-
efits (Delpeuch, Marie, Monnier, & Holdsworth, ity in both affective and schizophrenic disorders, a finding
1 2009). For individuals, reducing excess calories consistent with emerging evidence that inflammation may
offers medical and neuroprotective benefits (Prolla play a role in these disorders (Amminger et al., 2010).
& Mattson, 2001). This neuroprotection is espe- However, epidemiological studies of dementia and omega-3
cially important in light of recent findings suggest- fatty acid intake are as yet inconclusive (Freeman et al., 2()06).
ing that adult obesity may be associated with re- Epidemiological, cross-sectional, and clinical studies
duced cognitive function, as well as reduced white- suggest that omega-3 fatty acid supplementation may be
and gray-matter brain volume (Raji et al., 2010; therapeutic for several disorders. Again, depression has
• Wolf et al., 2007). Fortunately, pescovegetarian been the disorder most closely studied (Stahl, Begg, Weis-
diets are low in calories. inger, & Sinclair, 2008). Several meta-analyses suggest
that supplementation may be effective for unipolar, bipolar,
Multiple human and animal studies suggest that pescoveg- and perinatal depressive disorders as an adjunctive, and
etarian diets may prevent or ameliorate psychopathologies perhaps even as a stand-alone, treatment (Appleton, Rog-
across the life span (Gómez-Pinilla, 2008; Willis, Shukitt- ers, & Ness, 2010; Lin & Su, 2007), although at this stage,
Hale, & Joseph, 2009). Such diets may enhance cognitive supplementation is probably best used adjunctively. Ques-
and academic performance in children as well as ameliorate tions remain about optimal DHA and EPA doses and ratios,
affective and schizophrenic disorders in adults. They also although one meta-analysis found a significant correlation
offer neuroprotective benefits, as demonstrated by reduc- between dose and treatment effect, and a dose of 1,000 mg
tions in the incidence of age-related cognifive decline, of EPA daily is often mentioned, which requires several
Alzheimer's disease, and Parkinson's disease (Gómez- flsh oil capsules (Freeman et al., 2006; Kraguljac et al.,
Pinilla, 2008; Kang, Ascherio, & Groodstein, 2005; Morris, 2009).
Evans, Tangney, Bienias, & Wilson, 2006). Several studies
of the Mediterranean diet—including a meta-analysis of 12 There are also cognitive benefits of supplementation.
prospective studies with over 1.5 million subjects—found In infants, both matemal intake and feeding formula sup-
reductions in the incidence of both Alzheimer's and Par- plementation enhance children's subsequent cognitive per-
kinson's diseases (Sofi, Cesari, Abbate, Gensini, & Casini, formance (Freeman et al., 2006; Gómez-Pinilla, 2008; In-
2008). Dietary elements that appear to be particularly neu- nis, 2009). In older adults, flsh and flsh oil supplements
roprotective include fish, vegetables, and perhaps fruit, as appear to reduce cognitive decline but do not seem effec-
well as lower intake of animal fats (Gu, Nieves, Stem, tive in treating Alzheimer's disease (Fotuhi, Mohassel, &
Luchsinger, & Scarmeas, 2010; Kang et al., 2005; Morris et Yaffe, 2009).
al., 2006). Of enormous public health importance are recent The evidence on omega-3s for the treatment of other
findings suggesting that, owing to epigenetic factors, "the disorders is promising but less conclusive. Supplementa-
effects of diet on mental health can be transmitted across tion may benefit those with schizophrenia and Huntington's
generations" (Gómez-Pinilla, 2008, p. 575). disease as well as those exhibiting aggression in both
normal and prison populations. In children, omega-3s may
Supplements reduce aggression and symptoms of attention-deflcit/hy-
peractivity disorder (ADHD; Freeman et al., 2006; Song &
Growing evidence suggests that food supplements offer Zhao, 2007).
valuable prophylactic and therapeutic benefits for mental A particularly important finding is that flsh oils may
health. Research is particularly being directed to Vitamin prevent progression to flrst episode psychosis in high-risk
D, folie acid, SAME (S-adenosyl-methionine), and—most youth. A randomized, double-blind, placebo-controlled
of all—fish oil (Sarris, Schoendorfer, & Kavanagh, 2009). study was conducted of 81 youths between 13 and 25 years
Fish and fish oil are especially important for mental of age who had subthreshold psychosis. Administering flsh
health. They supply essential omega-3 fatty acids, espe- oil with 1.2 g of omega-3s once per day for 12 weeks
cially EPA (eicosapentaenoic acid) and DHA (docosa- reduced both positive and negative symptoms as well as the
hexaenoic acid), which are essential to neural function. risk of progression to full psychosis. This risk was 27.5%
Systemically, omega-3s are anti-inflammatory, counteract in controls but fell to only 4.9% in treated subjects. Par-
the pro-inflamatory effects of omega-6 fatty acids, and are ticularly important was the finding that benefits persisted
protective of multiple body systems. Unfortunately, mod- during the nine months of follow-up after treatment cessa-

tion (Amminger et al., 2010). Such persistence has not phers echoed similar claims, and the romantic poet William
occurred with antipsychotic medications, which also have Wordsworth (1807/1998, p. 307) famously described the
significantly more side effects. Although coming from only absence of such a healing connection:
a single study, these findings suggest another important
prophylactic benefit of fish oils. Getting and spending, we lay waste our powers:
Little we see in Nature that is ours;
With one exception, risks of fish oil supplementation
We have given our hearts away . . .
at recommended doses are minimal and usually limited to
mild gastrointestinal symptoms. The exception occurs in Yet today we are conducting a global experiment in which
patients on anticoagulants or with bleeding disorders, be- we increasingly spend our lives in artificial environments—
cause fish oils can slow blood clotting. Such patients walled inside and divorced from nature. Within these na-
should therefore be monitored by a physician. ture-free settings, noise is often annoying, and lighting is
Omega-3s modify genetic expression and as such are often artificial, of low intensity (often less than 10% of the
early exemplars of a possible new field of "psychonutri- light intensity on sunny days), and composed of nonnatural
genomics." Nutrigenomics is an emerging discipline that spectra and rhythms. As the burgeoning field of environ-
uses nutrients to modify genetic expression (Gillies, 2007). mental psychology demonstrates, the psychological costs
Because genetic expression is proving more modifiable, of such settings can be wide-ranging. These costs include
and nutrients more psychologically important than previ- dismptions of mood, sleep, and diumal rhythms. Cognitive
ously thought, psychonutrigenomics could become an im- costs include short-term impairment of attention and cog-
portant field. nition as well as long-term reduced academic performance
Space limitations allow only brief mention of another in the young and greater cognitive decline in the elderly
significant supplement. Vitamin D. Vitamin D is a multi- (Anthes, 2009; Higgins, Hall, Wall, Woolner, & Mc-
purpose hormone with multiple neural functions, including Caughey, 2005; Kuller, Ballal, Laike, Mikellides, & To-
neurotrophic, antioxidant, and anti-infiammatory effects nello, 2006). Further psychological difficulties occur in
(Chemiack, Troen, Florez, Roos, & Levis, 2009). Vitamin special populations such as those with Alzheimer's disease
D deficiency is widespread throughout the population, es- and postsurgical patients (Anthes, 2009; Ulrich, 2006).
pecially in the elderly, and exacts a significant medical toll;
several studies suggest associations with cognitive impair- Media Immersion and Hyperreality
ment, depression, bipolar disorder, and schizophrenia. In the last half century, a further artificial dimension has
Mental health professionals are therefore beginning to join been added. Increasingly, we now spend hours each day
physicians in recommending routine supplementation (usu- immersed in a fiood of multimedia stimuli, the neurological
ally 600 units per day) and, where indicated, testing pa- impact of which we are only beginning to understand.
tients' Vitamin D blood levels and modifying supplement However, some researchers have already concluded that
levels accordingly (Chemiack et al., 2(K)9). "the current explosion of digital technology not only is
There are further benefits to supplementation and pes- changing the way we live and communicate but also is
covegetarian diets. First, they have multiple general health rapidly and profoundly changing our brains" (Small &
benefits and low side effects. Second, they may ameliorate Vorgan, 2008, p. 44). This is hardly surprising given that
certain comorbid disorders—such as obesity, diabetes, and the average American spends several hours a day watching
cardiovascular complications—that can accompany some television and increasing amounts of time with digital
mental illnesses and medications. A diet that is good for the media (Putnam, 2000). As Thoreau (1854, p. 85) lamented,
brain is good for the body. As such, dietary assessment and people "have become the tools of their tools."
recommendations are appropriate and important elements Fortunately, television and digital media can some-
of mental health care. times be beneficial. Multiple meta-analyses show that al-
though aggressive television content can certainly foster
Nature negative attitudes and aggressive behavior, prosocial con-
Imagine a therapy that had no known side effects, was readily tent can foster positive behavior such as altruism (Mares &
available, and could improve your cognitive functioning at zero Woodard, 2005; Preiss, Gay le, Burrell, Allen & Bryant,
cost. Such a therapy has been known to philosophers, writers, and 2006). Likewise, digital immersion can benefit certain psy-
laypeople alike: interacting with nature. Many have suspected that chological and social skills in children, as the massive
nature can promote improved cognitive functioning and overall Digital Youth Project demonstrated (Ito et al., 2008).
well-being, and these effects have recently been documented. However, media immersion can also exact significant
(Berman, Jonides, & Kaplan, 2008, p. 1207) psychological and physical costs in both children and
adults, and a novel vocabulary has emerged to describe
For thousands of years, wise people have recommended multiple "technopathologies." Excessive media immersion,
nature as a source of healing and wisdom. Shamans seek especially when combined with heavy work demands, can
wildemess, yogis enter the forest, Christian Fathers retreat create psychological dysfunctions that include disorders of
to the desert, and American Indians go on nature vision
quests. Their experience is that nature heals and calms, • attention: continuous partial attention and attention
removes mental trivia, and reminds one of what really deficit trait
matters (Walsh, 1999). Romantic and existential philoso- • cognition: digital fog and techno-brain burnout

• overload: data smog and frazzing (frantic ineffec- Nature also offers the gift of silence. Modem cities
tual multitasking) abound in strident sounds and noise pollution, and the days
• addiction: screen sucking and on-line compulsive when Henry Thoreau (1849/1921, p. 291) could write of
disorder silence as a "universal refuge . . . a balm to our every
chagrin" are long gone. Unfortunately, urban noise can
and, of course, techno-stress (Small & Vorgan, 2008; exact significant cognitive, emotional, and psychosomatic
Wehrenberg & Coppersmith, 2008). tolls. These range, for example, from mere annoyance to
Yet the full implications of contemporary media and attentional difficulties, sleep disturbances, and cardiovas-
our divorce from nature may extend much further and cut cular disease in adults and impaired language acquisition in
far deeper than individual stress and pathology. There is an children (Clark & Stansfeld, 2007). By contrast, natural
exploding literature on their social effects (e.g.. Bracken & settings offer silence as well as natural sounds and stimuli
Skalski, 2010), and so powerful and pervasive is today's that attention restoration theory and research suggest are
multimedia reality, that for philosophers such as Jean Bau- restorative (Berman et al., 2008).
drillard, it constitutes a hyperreality—a simulated life-
world that seems more real than reality. So omnipresent are As yet, studies of specific psychotherapeutic benefits
media-manufactured images and narratives, and so di- are limited, and the benefits are sometimes conflated with
vorced are we from the direct events they portray, that we those of other therapeutic lifestyle factors. Though further
largely live in, believe in, and respond to this artificial research is clearly needed, immersion in nature does appear
hyperreal world rather than the natural world itself (Tiffin to reduce symptoms of stress, depression, and ADHD and
& Terashima, 2001). to foster community benefits (Taylor & Kuo, 2009; Taylor,
Kuo, & Sullivan, 2001). In hospital rooms that offer views
Evolutionary, Existential, and Clinical of natural settings, patients experience less pain and stress,
Concerns have better mood and postsurgical outcomes, and are able
to leave the hospital sooner (Devlin & Arneill, 2003; Ul-
We have barely begun to research the many implications of rich, 2006). Consequently, nature may be "one of our most
artificial environments, new media, hyperreality, and our vital health resources" (Mailer et al., 2006, p. 52). Given
divorce from nature. However, the problems they may pose the global rush of urbanization and technology, the need for
can be viewed in multiple ways. Biologically, we may be mental health professionals to advocate for time in, and
adapted to natural living systems and to seek them out. This preservation of, natural settings will likely become increas-
is the biophilia hypothesis, and multiple new fields—such ingly important.
as diverse schools of ecology, as well as evolutionary,
environmental, and eco- psychologies—argue for an inti- Relationships
mate and inescapable link between mental health and the Of all the means which are procured by wisdom to ensure hap-
natural environment (Esbjom-Hargens & Zimmerman, piness throughout the whole of life, by far the most important is
2009). In existential terms, the concem is that "modern the acquisition of friends. (Epicurus, quoted in D. Gordon, 1999,
man—by cutting himself off from nature has cut himself p. 35)
off from the roots of his own Being" (Barrett, 1962, p. The idea that good relationships are central to both physical
126), thereby producing an existential and clinical condi- and mental well-being is an ancient theme, now supported
tion generically described as nature-deficit disorder (Louv, by considerable research. Rich relationships reduce health
2005). risks ranging from the common cold to stroke, mortality,
Clinicians harbor multiple concems. Evolutionary and and multiple psychopathologies. On the positive side, good
developmental perspectives suggest that children in envi- relationships are associated with enhanced happiness, qual-
ronments far different from the natural settings in which we ity of life, resilience, cognitive capacity, and perhaps even
evolved, and to which we adapted, may suffer developmen- wisdom (J. H. Fowler & Christakis, 2008; Jetten, Haslam,
tal disorders, with ADHD being one possible example Haslam, & Branscombe, 2009). Analyses of different do-
(Bjorklund & Pellegrini, 2002). Likewise, evolutionary mains of life indicate that quality of life is "dominated by
theory and cross-cultural research suggest that for adults, the domain of intimacy" and that people with overt psy-
artificial environments and lifestyles may impair mental chopathology have a lower quality of life "most particu-
well-being and also foster or exacerbate psychopathologies larly in the domain of intimacy" (Cummins, 2005, p. 559).
such as depression (Buss, 2000). These clinical observations can now be grounded in
Therapeutic Benefits of Nature the emerging field of social neuroscience, which suggests
that we are interdependent creatures, hardwired for empa-
Fortunately, natural settings can enhance both physical and thy and relationship through, for example, the mirror neu-
mental health. In normal populations, these enhancements ron system (Cattaneo & Rizzolatti, 2009). So powerful is
include greater cognitive, attentional, emotional, spiritual, interpersonal rapport that couples can mold one another
and subjective well-being (Ho, Payne, Orsega-Smith, & both psychologically and physically. They may even come
Godby, 2003; Pryor, Townsend, Mailer, & Field, 2006). to look more alike, as resonant emotions sculpt their facial
Benefits also occur in special populations such as office muscles into similar pattem.s—a process known as the
workers, immigrants, hospital patients, and prisoners Michelangelo phenomenon (Rusbult, Finkel, & Kumashiro,
(Mailer, Townsend, Pryor, Brown, & St Leger, 2006). 2009).

Not surprisingly, good relationships are cmcial to of clients' relationships clearly warrants a central place in
psychotherapy. Multiple meta-analy.ses show that they ac- mental health care.
count for approximately one third of outcome variance,
significantly more than does the specific type of therapy Recreation and Enjoyable Activities
(Duncan et al., 2009), and that "the therapeutic relationship Through experiences of positive emotions people transform them-
is the comerstone" of effective therapy (Norcross, 2009, p. selves, becoming more creative, knowledgeable, resilient, socially
114). As Irvin Yalom (2002, p. 34) put it, the "paramount integrated, and healthy individuals. (Fredrickson, 2002, p. 123)
task is to build a relationship together that will itself be-
come the agent of change." Ideally, therapeutic relation- Involvement in enjoyable activities is central to healthy
ships then serve as bridges that enable patients to enhance lifestyles, and the word recreation ("re-creation") summa-
life relationships with family, friends, and community. rizes some of the many benefits (Fredrickson, 2002). In
behavioral terms, many people in psychological distress
The need may be greater than ever, because social
suffer from low reinforcement rates, and recreation in-
isolation may be increasing and exacting significant indi-
creases reinforcement. Recreation may overlap with, and
vidual and social costs. For example, considerable evidence therefore confer the benefits of, other TLCs such as exer-
suggests that, compared with Americans in previous de- cise, time in nature, and social interaction. Recreation can
cades, Americans today are spending less time with family involve play and playfulness, which appear to reduce de-
and friends, have fewer intimate friends and confidants, and fensiveness, enhance well-being, and foster social skills
are less socially involved in civic groups and communities and maturation in children (Lester & Rus.sell, 2008) and
(McPherson, Smith-Lovin & Brashears, 2006; Putnam, perhaps also in adults (G. Gordon & Esbjorn-Hargens,
1995, 2000). However, there is debate over, for example, 2007). Recreation can also involve humor, which appears
whether Internet social networking exacerbates or compen- to mitigate stress, enhance mood, support immune function
sates for reduced direct interpersonal contact and over the and healing, and serve as a mature defense mechanism
methodology of some social surveys (Fischer, 2009). Yet (Lefcourt, 2002).
there is also widespread agreement that "the health risk of Further recreational activities include art and other
social isolation is comparable to the risks of smoking, high aesthetic pleasures, which have long been employed for
blood pressure and obesity. . .. [while] participation in self-healing. For example, the great 19th-century philoso-
group life can be like an inoculation against threats to pher John Stuart Mill—one of history's outstanding intel-
mental and physical health" (Jetten et al., 2009, pp. 29, 33). lectual prodigies—spent his childhood force-feeding him-
Beyond the individual physical and mental health self with facts. However, when at 20 he fell into a severe
costs of greater social isolation are public health costs. In depression, he tumed to the arts—music, painting, and
"perhaps the most discussed social science article of the especially poetry—for self-therapy, and these, his biogra-
twentieth century" (Montanye, 2001, para. 1), and in a pher reported, were what "saved him" (Gopnik, 2008).
subsequent widely read book. Bowling Alone: The Col- Many studies suggest that enjoyable recreational ac-
lapse and Revival of American Community, the political tivities, and the positive emotions that ensue, foster multi-
scientist Robert Putnam (1995, 2000) focused on the im- ple psychological and physical benefits (G. Gordon &
portance of social capital. Social capital is the sum benefit Esbjorn-Hargens, 2007; Ho et al., 2003; Lester & Russell,
of the community connections and networks that link peo- 2008). However, some studies of recreation include and
ple and foster, for example, beneficial social engagement, conflate additional healthy life.style factors such as exer-
support, trust, and reciprocity (Bhandari & Yasunobu, cise, relaxation, and time in nature, and there are few
2009). Social capital seems positively and partly causally clinical guidelines. Mental health professionals will there-
related to a wide range of social health measures—such as fore need to use their clinical skills to assess and support
reduced poverty, crime, and drug abuse—as well as in- individual patients' interests. "The bottom line message is
creased physical and mental health in individuals. Yet that we should work to cultivate positive emotions in
considerable evidence suggests that social capital in the ourselves and in those around us not just as end states in
United States and other societies may have declined sig- themselves, but also as a means of achieving psychological
nificantly in recent decades (Putnam, 1995, 2000). growth and improved psychological and physical health
In short, relationships are of paramount importance to over time" (Fredrickson, 2002, p. 120).
individual and collective well-being, yet the number and
intimacy of relationships seem to be declining. Moreover,
Relaxation and Stress Management
"the great majority of individuals seeking therapy have Chronic Stressors can exact a major toll across multiple
fundamental problems in their relationships" (Yalom, organ systems and levels. This toll extends from psycho-
2002, p. 47). Clients' relationships are a major focus of, for logical to physiological to chemical (e.g., oxidative stress)
example, interpersonal and some psychodynamic psycho- to genomic expression (hence the new field of psychosocial
therapies (Shedler, 2010). Yet clients' interpersonal rela- genomics; Dusek et al., 2008). Even though stress is uni-
tionships often receive insufficient attention in clinical and versal, few people are trained in managing it. In addition,
training settings compared with intrapersonal and pharma- humans now face an array of novel Stressors for which
cological factors (Pilgrim, Rogers, & Bentall, 2009; Shed- there are no evolutionary or historical precedents. Many
ler, 2010). Focusing on enhancing the number and quality people therefore respond unskillfully or even self-destruc-

tively, aided and abetted by pervasive unhealthy influences Meditation can also be beneficial when combined with
such as advertising, media role models, and novel psycho- other therapies. The best known combinations are dialec-
active drugs (Buss, 2000). Yet many skillful strategies for tical behavior therapy (primarily used for borderline per-
stress management are now available, ranging from life- sonality disorder), mindfulness-based stress reduction, and
style changes to psychotherapy to self-management skills. mindfulness-based cognitive therapy. A meta-analysis of
Beneficial TLCs include almost all those discus.sed in this mindfulness-based therapies found large effect sizes for
article—especially exercise, recreation, relationships, and anxiety and depressive symptoms of 0.95 and 0.97, respec-
religious or spiritual involvement—and .specific self-man- tively, and therapeutic gains were maintained at follow-up
agement skills can both complement and foster these TLCs. (Hofmann et al, 2010).
It is now clear that meditation, either alone or in
Self-Management Skills
combination with other therapies, can be beneficial for both
Specific stress management skills include somatic, psycho- normal and multiple clinical populations. However, it is
logical, and contemplative approaches. Somatic skills span less clear how different meditation practices compare or
both ancient Oriental and contemporary Western tech- how meditation compares with other therapies and self-
niques. The Chinese mindful movement practices of tai chi regulation strategies such as relaxation, feedback, and self-
and qui gong are increasingly popular in the West, and hypnosis (Ospina et al, 2007; Walsh & Shapiro, 2006).
research studies suggest they are associated with both phys- Yoga may also be helpful for stress and mood disor-
ical and psychological benefits (Kuramoto, 2006). A re- ders. However, studies on yoga are fewer, and reviews
view of 15 randomized controlled trials of tai chi's effects have drawn cautious conclusions (da Silva, Ravindran, &
on psychosocial well-being found significant benefits for Ravindran, 2009; Kirkwood, Rampes, Tuffrey, Richardson,
the treatment of anxiety and depression but also noted the & Pilkington, 2005; Lipton, 2008; Pilkington, Kirkwood,
mixed quality of the trials (Wang et al, 2009). Rampes, & Richardson, 2005).
Western self-management skills include mental ap- In addition to its benefits for relaxation and stress
proaches such as self-hypnosis and guided imagery (Trakh- management, meditation may also enhance measures of
tenberg, 2008) as well as somatic approaches, especially psychological capacities, health, and maturity in both pa-
muscle relaxation therapies that center on systematically tients and nonpatients (Walsh & Shapiro, 2006). Particu-
tightening and relaxing major muscle groups. By doing larly important to health care professionals are findings that
this, patients learn to identify and release muscle tension meditation can enhance valued caregiver qualities such as
and eventually to self-regulate both muscle and psycholog- empathy, sensitivity, emotional stability, and psychological
ical tensions. Muscle relaxation skills are widely used for maturity while reducing distress and burnout (Shapiro &
the treatment of anxiety disorders, including panic and Carlson, 2009). On the cognitive side, studies suggest that
generalized anxiety disorders, and meta-analyses reveal meditation can enhance some measures of cognition and
medium to large effect sizes (Manzoni, Pagnini, Castel- may reduce age-related cognitive losses and corresponding
nuovo, & Molinari, 2008). brain shrinkage (Pagnoni & Cekic, 2007; Xiong & Do-
Contemplative skills such as meditation and yoga are raiswamy, 2009). The universality of stress, as well as the
now practiced by millions of people in the United States multiple benefits of both lifestyle changes and self-regula-
and by hundreds of millions worldwide (Walsh, 2011). tion skills for managing stress, suggests that these TLCs
Concomitantly, an explosion of meditation research has and self-regulation skills deserve to be central components
demonstrated a wider array of effects—psychological, ther- of health professionals' training, personal and professional
apeutic, neural, physiological, biochemical, and chromo- practice, and public outreach.
somal—than are associated with any other psychotherapy
(Walsh, 2011; Walsh & Shapiro, 2006). Religious and Spiritual Involvement
Considerable research suggests that meditation can Religious and spiritual concerns are vitally important to
ameliorate a wide array of (especially stress-related) psy- most people and most patients. Some 90% of the world's
chological and psychosomatic disorders in both adults and population engages in religious or spiritual practices; these
children (Arias, Steinberg, Banga, & Trestman, 2006; practices are a major means of coping with stress and
Black, Milam, & Sussman, 2009; Chiesa, 2009; Dusek et illness; and most patients say that they would welcome
al, 2008). Multiple studies, including meta-analyses, show their health professionals' inquiring about religious issues
that meditation can reduce stress measures in both clinical (Koenig, 2002). Yet few health professionals do. This lack
and normal populations (Chiesa & Serretti, 2009; Hof- of attention may be unfortunate given the prevalence and
mann. Sawyer, Witt, & Oh, 2010). Partially responsive importance of religious and spiritual practices, their many
psychosomatic disorders include, for example, cardiovas- influences on lifestyle and health, their impact on therapeu-
cular hypertension and hypercholesterolemia, hormonal tic relationships and effectiveness, and the deep existential
disorders such as primary dysmenorrhea and Type 2 dia- issues they open (J. W. Fowler, 1995; Koenig, 2009).
betes, asthma, and chronic pain (Anderson, Liu, & Kryscio, Considerable research suggests a complex but usually
2Ó08; Shapiro & Carlson, 2009). Responsive psychological beneficial relationship between religious involvement and
difficulties include, among others, insomnia, anxiety, de- mental health. The most massive review to date found
pressive, eating, and borderline personality disorders (Di- statistically significant positive associations in 476 of 724
donna, 2009; Shapiro & Carlson, 2009). quantitative studies (Koenig, McCullough, & Larson,

2001 ). In general, religious or spiritual involvement is most that view religion as, for example, always regressive or
likely to be beneficial when it centers on themes such as always transcendental invariably overlook this develop-
love and forgiveness and is likely to be less helpful or even mental perspective. Examples of reductionistic interpreta-
harmful to mental health when themes of punishment and tions that view religion as necessarily regressive or patho-
guilt predominate. logical include the writings of the so called "neoatheists,"
Beneflts span an array of health measures. Mental such as the recent extremely popular books The God De-
health beneflts include enhanced psychological, relational, lusion (Dawkins, 2006), The End of Faith (Harris, 2005),
and marital well-being, as well as reduced rates of disor- and God Is Not Great (Hitchens, 2007), all of which are
ders such as anxiety, depression, substance abuse, and ignorant of developmental research. Unfortunately, the
suicide. For physical health, religious involvement seems widespread failure to recognize developmental differenc-
beneflcially related to both speciflc disorders such as hy- es—in faith, morality, values, ego, worldview, and more—
pertension and to nonspeciflc mortality rates (Koenig et al., and their far-reaching implications for religion and multiple
2001). Strikingly, those who attend religious services at other areas of life seems a signiflcant factor underiying
least weekly tend to live approximately seven years longer many contemporary cultural conflicts (Walsh, 2009; Wil-
than those who do not, even when factors such as baseline ber, 2006).
health and health behaviors are statistically controlled Of course, religious behavior can sometimes be re-
(Koenig et al., 2001). Important mediating and contributory gressive or pathological. However, religious behavior can
factors likely include service to others and especially social also both express and foster healthy, mature, and even
support. Contemplative practices such as meditation offer exceptionally mature development. In fact, a classic goal of
further psychological, somatic, and spiritual beneflts (Di- spiritual practices such as meditation is to foster postcon-
donna, 2009; Shapiro & Carlson, 2009; Walsh & Shapiro, ventional development through, for example, bhavana
2006). (mental cultivation) in Buddhism and lien-hsin (reflning the
mind) in Taoism (Walsh & Shapiro, 2006). Contemporary
Religion, Spirituality, and Psychological research and meta-analysis are supportive, because medi-
Development tators tend to score higher on measures of ego, moral, and
It is important for mental health professionals to recognize cognitive development as well as self-actualization, coping
that there are multiple levels of religious development. skills and defenses, and states and stages of consciousness
These levels range from preconventional to conventional to (Alexander & Langer, 1990; Alexander, Rainforth, &
postconventional (or from prepersonal to personal to Gelderloos, 1991). Ideally, religious and spiritual traditions
transpersonal) and are associated with extremely different offer both legitimacy (support for people's current level of
kinds of religious faith, practice, behavior, and institutions psychological and faith development) as well as authentic-
(J. W. Fowler, 1995; Wilber, 2005, 2006). ity (support for maturation beyond current levels) (Wilber,
For example, consider the developmental stages of 2005). Given the significance of religious and spiritual
religious faith. At the preconventional level, mythic-literal involvement, it seems important for therapists to be famil-
faith involves an unreflective, literal acceptance of cultur- iar with developmental and other key issues and, where
ally provided beliefs. At the synthetic-convendonal level, appropriate, to inquire about and support healthy involve-
people begin to create their own individual, but still largely ment in this domain.
unreflective, synthesis of diverse conventional beliefs. At
later postconventional stages, exemplifled by conjunctive
Contribution ond Service
and universalizing faith, individuals critically reflect on From ancient times, service and contribution to others have
conventional assumptions, open themselves to multiple been regarded as virtues that can beneflt both giver and
perspectives, confront paradoxes, and extend their care and receiver (Walsh, 1999). The world's major spiritual tradi-
concem to all peoples (J. W. Fowler, 1995; Wilber, 2006). tions emphasize that, when viewed correctly, service is not
When developmental differences go unrecognized, necessarily a sacriflce but rather can foster qualities that
problems ensue. For example, the views of one level are serve the giver—such as happiness, mental health, and
taken as normative, and those at this level tend to assume spiritual maturity. Altruism is said to reduce unhealthy
that people at other levels are mistaken, misguided, malev- mental qualities such as greed, jealousy, and egocentricity
olent, or disturbed (Wilber, 2005). Many contemporary while enhancing healthy qualities such as love, joy, and
religious and cultural conflicts appear to reflect these kinds generosity (Hopkins, 2001; Walsh, 1999). The beneflts of
of cross-level misunderstandings (Walsh, 2009). service are also said to extend to healing, such that healing
This developmental perspective brings new clarity to oneself and others can be intimately linked. Multiple myths
many religious and spiritual issues. For example, it makes and healing traditions describe wounded healers, people
clear that religions are not only culturally diverse but also who by virtue of their own illness leam to heal others and
developmentally diverse, and that mental health profes- may thereby be healed themselves.
sionals need to be sensitive to both kinds of diversity. In our own time, both theory and research point to
Religion can be an expression of immaturity, conventional con-elations between altmism and measures of psycholog-
maturity, and postconventional maturity, and of corre- ical and physical health. Multiple studies, including those
sponding motives and concerns ranging from egocentric to that control for prior health factors, suggest that people
ethnocentric to worldcentric (Wilber, 2006). Interpretations who volunteer more are psychologically happier and

healthier, are physically healthier, and may even live longer have long been considered central elements of a life well
(Borgonovi, 2009; Grimm, Spring, & Dietz, 2007; Post, lived. Now they can also be considered central elements of
2007). The so-called "paradox of happiness" is that spend- a healthy life.
ing one's time and resources on others can make one
happier (Walsh, 1999). Discussion
Altmists of all ages may experience a "helpers' high"
A culture's technology has far-reaching effects on people's
(Post, Underwood, Schloss, & Hulbert, 2002). Even re-
psychology and lifestyles (Wilber, 2000), and modem tech-
quired community service for adolescents seems to effect
nology is now affecting our psychology, biology, society,
long-term positive psychological changes, and even man-
and lifestyles in ways we are only beginning to compre-
dated monetary donations can make college students hap-
hend. Moreover, technological innovations and their life-
pier than spending the money on themselves (Dunn, Aknin,
style effects are changing "more quickly than we know
& Norton, 2008). Erik Erikson (1959) famously suggested
how to change ourselves" (Putnam, 2000, p. 402). Many of
that "generativity" (care and concern for others, and espe-
the resultant costs are doubtless as yet unrecognized, and
cially for future generations) may be a hallmark of suc-
this raises a disconcerting question: Could some of our
cessful maturation. Moreover, altruism has a positive social
patients be "canaries in the coal mine," waming us of ways
contagion or multiplier effect. For example, cooperative
of life that may exact a toll on us all? This is a question that
behaviors cascade through social networks to induce fur-
health professionals will need to confront increasingly as
ther cooperation in others (J. H. Fowler & Christakis,
technological, environmental, and lifestyle changes accel-
2010), and at the community level, service is a key con-
erate.
tributor to social capital (Putnam, 2000).
In summary, considerable research shows positive re- Interactions Among Therapeutic Lifestyle
lationships between altruistic behavior and multiple mea- Factors
sures of psychological, physical, and social well-being.
However, there are important qualifiers. Major exceptions Fortunately, individual TLCs appear to counter many med-
include the caretaker burnout experienced by overwhelmed ical and psychological complications of contemporary
family members caring for a demented spouse or parent. pathogenic lifestyles. This raises a hopeful possibility:
Furthermore, the kind of motivation powering the prosocial Might multiple TLCs be even more effective? There is
behavior affects outcome. Whereas service motivated by evidence for this possibility in both animal studies and
pleasure in helping is associated with multiple positive clinical medicine. For example, physical activity increases
measures (such as positive affect, self-esteem, self-actual- neuronogenesis in the rat hippocampus. However, the ef-
ization, and life satisfaction), this association may not hold fect is maximal only when the animals are exposed to a rich
when service is driven by a sense of internal pressure, duty, social environment rather than living in isolation (Strana-
and obligation (Gebauer, Riketta, Broemer, & Mai, 2008). han, Khalil, & Gould, 2006). Similarly, in his program to
Psychotherapists repeatedly rediscover the healing po- reverse coronary arteriosclerosis. Dean Ornish employed
tentials of altmistic behavior for both their patients and four TLCs—exercise, vegetarian diet, relaxation and stress
themselves. Alfred Adler emphasized the benefits of "so- management, and social support. Each proved beneficial,
cial interest," and helping other group members contributes and the effects were additive (Pischke et al., 2008). Might
to the effectiveness of group therapy and support groups this also be true for psychological disorders? Quite possi-
such as Alcoholics Anonymous (Duncan et al., 2009). bly, but as yet we have no clear answer.
Likewise, therapists often report that helping their patients
Difficulties of Implementing Therapeutic '
can enhance their own well-being (Yalom, 2002). Wisely
Lifestyle Changes
perceived, altruism is not self-sacrifice but rather enlight-
ened self-interest (Walsh, 1999). As the Dalai Lama put it, Given the many advantages of TLCs, why have mental
"If you're going to be selfish, be wisely selfish—which health professionals been so slow to adopt them? The
means to love and serve others, since love and service to reasons involve patients, therapists, and society. Effective
others bring rewards to oneself that otherwise would be public health programs will therefore need to address all of
unachievable" (quoted in Hopkins, 2001, p. 150). them.
These benefits of altruism hold major implications for For patients, TLCs can require considerable and sus-
our understanding of health, lifestyle, and therapy. On the tained effort, and many patients feel unable or unwilling to
basis of their research findings. Brown, Nesse, Vinokur, tackle them. Patients often have little social support, little
and Smith (2003) wrote an article titled "Providing Social understanding of causal lifestyle factors, and a passive
Support May Be More Beneficial Than Receiving It" and expectation that healing comes from an outside authority or
concluded that interventions "designed to help people feel a pill (Duncan et al., 2009). Societally, whole industries are
supported may need to be redesigned so that the emphasis geared toward encouraging unhealthy choices. Patients
is on what people do to help others" (p. 326). Other contend with a daily barrage of psychologically sophisti-
researchers quipped, "If giving weren't free, pharmaceuti- cated advertisements encouraging them, for example, to
cal companies could herald the discoveries of a stupendous consume alcohol, nicotine, and fast food in the never-
new drug called 'Give Back'—instead of 'Prozac'" (Post & ending search for what the food industry calls the "bliss
Niemark, 2007, p. 7). Contribution and service to others point" of "eatertainment" through "hypereating" (Kessler,

2009). Unfortunately, one can never get enough of what of contemporary lifestyles, such interventions may be es-
one does not really want, but one can certainly ruin one's sential. In the 21st century, therapeutic lifestyles may need
health and fife trying (Walsh, 1999). to be a central focus of mental, medical, and public health.
Therapists also face challenges. The first is simply to
become familiar with the large literature on TLCs. The REFERENCES
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Lifestyle and Mental Health

October 2011 • American Psychologist 579

580 October 2011 • American Psychologist

October 2011 • American Psychologist 581

582 October 2011 • American Psychologist

October 2011 • American Psychologist 583

584 October 2011 • American Psychologist

October 2011 • American Psychologist 585

586 October 2011 • American Psychologist

October 2011 • American Psychologist 587

588 October 2011 • American Psychologist

October 2011 • American Psychologist 589

590 October 2011 • American Psychologist

October 2011 • American Psychologist 591

592 October 2011 • American Psychologist

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