Table Of ContentActivity for Mental
Health
Brad Bowins
Founder, Psychiatry, Centre for Theoretical Research in
&
Psychiatry Clinical Psychology, Toronto, Ontario, Canada
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To my wife, Lynne Bowins, and
children, Emma, Mark, and Breanna,
as well as all those who try their best
to stay active.
Preface: activity for mental
health
Diverse forms of activity are potentially capable of improving
mentalhealthinahighlycost-effectivefashion.Currenttreatments
for mental illness are not universally beneficial and high-costs
block their application to many people in need of help. In addi-
tion, well-being levels in thegeneral population are not ideal with
definiteroomforimprovement.Hence,ahighlycost-effectiveand
robust strategy for both treating mental illness and advancing
mental health in the general population is greatly needed. That
strategy is activity! Physical, social, nature, cognitive, art/hobby,
and music forms are applicable. Activity For Mental Health is the
only book providing evidence and reasons for why these diverse
typesofactivitybothtreatmentalillnessandadvancementalhealth
in the general population. Mental health providers, researchers,
students, policy-makers, and consumers will benefit from the
comprehensive review of studies and exploration for why each of
these forms of activity, and activity in general, is so effective.
Evidence levels are summarized revealing the current status of
research efforts. The reasons accounting for the mental health
benefits of activity are intriguing and ground the evidence in a
scientific foundation.
Consistent with the greater attention typically devoted to
negativestates,muchoftheemphasisinmentalhealthresearchand
treatmentisonproblemsandalleviatingthem.Activity,incontrast,
is a very positive and natural approach to mental health issues,
underscoring its effectiveness. Ultimately, the robustness of ac-
tivity derives from the science of evolution and human hunting-
gathering origins, where activity was essential, in contrast to our
ix
x
Preface: activity for mental health
more sedentary tree-dwelling primate relatives. Consequently,
humanmentalandphysicalhealthreliesonactivity. Inaddition to
the coverage of various forms of activity in separate chapters,
Behavioral Activation Treatment is presented as it informs
regarding why activity is so therapeutic, based on behavioral
activationandinhibitionsystemsandtheirroleinhumanevolution.
However, the focus is on the informal versiondactivity
therapydwhen applied to treat mental illness, and activity for the
general population. The goal is to elevate activity to the status it
warrants for advancing mental health and motivate people to be
active.
Chapter 1
Introducing activity
(therapy) for mental health
This is a book about activity focused strictly on mental health. In
contrast to physical health where the emphasis is only on physical
activity,severalformsofactivityapplytomentalhealth.Thereare
physical, social, nature, mental (cognitive), art/hobby, music, and
potentially other forms of activity on their own or combined. This
bookexplorestheevidence forhow these diverseformsofactivity
impact mental health and the reasons why this occursdthe
rationale. Although the term “activity” appears clear, it is always
helpful to start with a definition. Merriam-Websterdefines activity
as: the quality or state of being active. From this, we go to their
definition of active: characterized by action rather than by
contemplation or speculation, as in an active life. One level
further,wegettotheirdefinitionofaction:athingdone.Fromthis
multileveldefinition,wecansaythat activityisthequality orstate
of getting something done!
Myinterestintherolethatactivityplaysinmentalhealthrequires
some information about my background. I am a psychiatrist with
over 25years of experience, mostly focused on adults, although I
havetreatedolderadolescentsinauniversitystudenthealthsetting.
My practice is in Ontario, Canada, a setting that still allows psy-
chiatrists to provide diverse forms of psychotherapydin many or
mostpartsoftheworldtheroleofapsychiatristhasbeenreducedto
assessments and brief mostly medication focused visits. Through
experience,Ihavefoundthatthebestapproachisoftenaneclectic
one, tailoring treatment to the needs of the person. As a medical
ActivityforMentalHealth.https://doi.org/10.1016/B978-0-12-819625-0.00001-0 1
Copyright©2020ElsevierInc.Allrightsreserved.
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Activity for Mental Health
doctor (psychiatrist trained in medicine), I tend to apply the term
patient,butmosttherapistssayclient,soIwillgowiththelatterterm.
My clients typically benefit from this eclectic approach involving
diverse forms of psychotherapy and/or medication as required. In
addition to this practice, I conduct research, mostly theoretical,
being the founder of the Centre for Theoretical Research in Psy-
chiatry and Clinical Psychology (psychiatrytheory.com), an online
resource. My research interests are also eclectic, frequently moti-
vatedbywhatIseeinmyownpractice,andIensurethatthetheories
generatedfitwellwithclinical realities, and ofcoursethe research
evidence. Within the context of eclectic therapy and research, and
also in linewith my active lifestyle, I became intrigued by Behav-
ioralActivationTherapy(BAT).Therearedifferentversionsofthis
therapeuticapproach,butallfocusonincreasingreinforcingactiv-
ity. Applying it to my clients, I quickly noted the benefits. A key
principle of this form of therapy is approaching sources of rein-
forcement in a graded fashion, starting with the least difficult and
progressing to more challenging ones. The topic of formal BAT is
addressedintheBehavioralActivationTherapychapter.Thisbook
is not about BAT, but instead covers activity and informal activity
therapywhenappliedtotreatmentalillness.
Regarding informal and formal versions of therapy, I came to
appreciatethevalueoftheformer.Earlyon,Ipracticedmoreformal
cognitive therapy focused on thoughts, giving clients homework
type assignments and going over this work during sessions. What
happens though when you give many or most people homework?
Right, they do not do it or only partially do it as many teachers
rapidly discover. I would arrive at thewaiting room to see a client
feverishlywritingthingsdownthatweresupposedtobedoneduring
theweek,andmanyjustcameinmakingexcusesforwhyitwasnot
completed. At the university health service, students had to be
“screened” to see if they would do the cognitive therapy assign-
ments.Consider thisforasecondduniversitystudents screenedto
seeifthey,ofallpeople,couldandwoulddoassignments!Thenithit
me, a real epiphany: why bother with formal versions for most
people and instead apply informal versions adjusting them to the
capacity, needs, and interests of the client. I noted that this more
Introducing activity (therapy) for mental health Chapter | 1 3
informal approach works very well in the context of eclectic psy-
chotherapy,andIhaveneverlookedback.Informalandformalare
reallyonacontinuumofformality,soIdoprovidetherapyconsistent
withBATtosomeclients.
One example of a more formal BAT intervention demon-
strating thevalue of activity therapy involves a client (I’ll try and
stick to this term but forgive me for the odd slip) in a state of
profound depression. Wewill refer to her as Jennifer, not her real
name. Jennifer’s family doctor contacted me in a state of
desperationoverwhattodowithher,havingtriedmedication and
lengthy supportive talks, but nothing worked. A few months
prior, she had been released from a local major psychiatric hos-
pital after a stay of several months. Staff at the hospital tried
multiple medications, many rounds of electroconvulsive therapy
(ECT) inducing seizures essentially, and various talk approaches.
For the most part, she remained depressed, unmotivated, and
inactive staying in bed. The ECT gave her severe headaches, but
not much else. Fairly confident that she was not going to take her
life,andatleastabletogetoutofbedforsomeneeds,thehospital
staffreleasedhertothecareofherhusbandandteenagedaughter.
At this point began the family doctor’s stress over what to do.
Her husband brought Jennifer to our first session, and several
following ones. She looked depressed and lethargic with limited
speech, and almost always in response towhat I asked; no sponta-
neousconversation.Itdidnottakeapsychiatristtodiagnosesevere
depression. Thankful that I knew about activity therapy and was
experienced with its application, I informed her that the only way
she was going to get out of this was by one thing, and one thing
onlydactivity. In response to blank looks from both her and her
husband,I explained that physical, mental, and social activity is at
leastaseffectiveasmedicationforseveredepression(Iwashoping
more effective given the abysmal response to date). Although
skeptical, both agreed to try it. I laid out a plan of graded activity
startingwiththemostbasic.Regardingphysicalactivity,shewasto
get out of bed, despite not wanting to, even if all this entailed was
sittingonthelivingroomcouch.Socialactivitymeantrespondingto
herhusbandanddaughter.Formentalactivity,shewasgoingtoread
4
Activity for Mental Health
anything, even the headlines on a newspaper or part of a young
child’sbook.Forthefirstfewsessions,shestruggledwiththisbasic
levelofactivity,butthenwasokaywithit.
Consistent with the graded level approach, we moved to
walking within the house for physical activity, listening to phone
messages from friends and relatives for social activity, and
reading the easiest to absorb articles or even just a paragraph.
Again, there was some delay, but faster than at the start. We
progressedtowalksintheyardwithherhusbandand/ordaughter,
conversing with people including returning calls (not initiating),
and longer reading sessions. Next came walks along the street
with her husband and/or daughter, initiating conversation and
calls to friends and family, and reading more involved material.
As she achieved progressively more advanced and challenging
forms of physical, social, and mental activity, she began to feel
better and more energized given the reinforcement derived from
those activities, and was less hopeless and downcast. Carefully
note that there was no focus on getting her to feel better first, it
was all about activity. Within 6months, she was coming to ses-
sions on her own, walking several blocks without company, and
seeing friends she had not interacted with for well over a year.
Sheclaimed thatshe no longer felt depressed. For Jennifer, itwas
all about the activity that got her out of the depression, to the
great relief of her family doctor, relatives, and friends. We will
return to Jennifer’s story from time to time, as there are some
intriguing aspects that inform regarding activity. Suffice it to say
at this point, that after several years she remains free of signifi-
cant depression, and is actively managing her own life, with no
further hospital admissions.
If activity was able to get Jennifer out of such a profound
depression when every other approach failed miserably, then it is
reasonable to believe that activity can be helpful for milder
depression and also optimizing mental health in those lacking any
mental illness, who we often say are normal, but what is normal?
Hence, we will just say, those lacking any formal mental illness.
However,asreasonableasthissounds,itisimportanttoconsiderthe
research evidence for activity and mental health, as well as the
