Previous articles in this column have described the benefits of mobilizing the patient in the direction of lifestyle changes and prioritizing self care. Development of “healthy routines” in the areas of Biological, Psychological, Social, and Spiritual needs is THE crucial element of “Wellness” or “Fitness.”
Relapse prevention is an important part of our work. Teaching patients to take their medications regularly is part of routine maintenance of their biological needs. Encouraging healthy diet and exercise also fits that category (how often do patients actually change these behaviors?). We must also encourage and guide patients to understand and tend to their emotional needs, social and spiritual needs. We can explain that taking better care of their body, their social and spiritual needs will help them emotionally; and working on emotional “self-growth” will likewise help them in each of the other areas.
Psychological needs include techniques and time to calm and clear the mind. Other examples of psychological needs are activities where we feel productive and/or creative. We all need love and compassion, and feeling compassion towards others also helps us psychologically. We also need activities where we lose our self, such as described in Flow by Csikszentmihalyi.
We all have social needs, which vary from the minimal interdependence we have on each other for food etc. to more complex social needs which may help us biologically (i.e. physical activities with others), psychologically (sense of “belonging,” love, compassion, productivity, creativity and pro-creativity), and also helps with spiritual needs.
Spiritual needs may be less obvious and historically we as Psychiatrists have “punted” in this department. Yet if you think about it spiritual issues and psychological conflicts are closely entwined. Issues about self worth, hope, judgment of self, guilt, acceptance, forgiveness, are just a few. We can quickly point out the difference between “spirituality” and “religion,” which for some people has a negative connotation or may lack a spiritual element. Examples of spiritual needs would be appreciating the natural beauty of a sunset, or taking time to acknowledge the awesomeness of the universe (whether or not you believe in a “Creator”).
Historically many psychotherapies have focused on understanding why people act or think the way they do, and trying to resolve breaches in relationships through the new relationship with therapist. These are helpful, but all too often therapy is bogged down or over-focuses on these areas before ever getting to the patient actually changing the way they think or act. “Understanding” is not a goal but a means toward goals such as improved self esteem, self care, and decision-making. It is often enough for patients to understand that they didn’t receive the love they needed growing up. That they never learned how to understand, validate, and regulate their emotions. That because of not getting what they needed as a child, they developed negative beliefs, couldn’t feel good about themselves, or develop psychological skills to help connect with or compete with others. Psychological healing can come from clarifying and supporting healthy emotions such as grief.
Primarily we can focus on the Psychological realm, and we can unblock resistances and obstructions to self care such as self-worth issues, prioritization of own needs before others’, assertiveness, and time management. One valuable cognitive technique is to teach patients that their negative beliefs about themselves are ingrained, they’ve grown up around them, and to some degree will always be part of them. They should not wait for these negative beliefs to change before beginning to take care of themselves. Teaching people that they can learn to actually change their emotions is also powerfully motivating. More on motivational techniques in a future column.
Skills-based therapies teach the patient to take charge of their own life- better care of self, better decisions, more deliberate actions. Self-direction, and self-regulation, to the extents our environment and interdependence allow. In order to be effective, we have to be present and clear-minded. We have to be able to read our emotions clearly. We have to be able to examine our automatic thoughts, biases, and judgments and question them. We have to be able think through without immediately reacting and choose the actions that fit our values and priorities. When we encourage our patients to practice Mindfulness this is what they’re learning to do.
We don’t have to teach it ourselves, but we should refer patients to resources that do. Dialectical Behavior Therapy, Mindfulness-based Cognitive Therapy, many books, Audio CD’s and Spiritual retreats describe and teach Mindfulness. Here’s why it’s important: this is a very teachable technique. The patient practices sorting out past, present, and future thinking (and being). Patients are taught to observe their emotions, to describe them, to not run away, judge, or immediately act on them. They’re taught to examine their thoughts and impulses, accept, not judge them, but also recognize distortions, biases and other “programming” from the past. They learn to practice compassion, towards others and self. This helps immensely with self-esteem, anger management, intimacy, and many other areas.
Mindfulness practice alone does a lot. When we understand and refer to it with our patients it adds great depth to our practice and to our patients’ lives. Mindfulness concepts can be applied everywhere. Patients can learn “Emotion regulation skills” so that as they learn to recognize anxiety or other intense emotions they can apply techniques to calm themselves or change what they are feeling. In PTSD teaching mindfulness and emotion regulation skills before going into past trauma allows the patient to approach the past when ready with new adult skills, i.e. actively being able to separate past from present, and confident that they can calm themselves when they start to become emotionally dysregulated.
Mindfulness helps with prioritization, time management… many areas. We should have discussions with patients about their priorities and goals, and encourage them to develop values. Many of our patients are so focused on pleasing others or “figuring out” the meanings of things that they haven’t taken time to develop values the can call they’re own. These values should include routine self care, and become the cornerstone or foundation for a new life. Applying these skills and seeing results is very motivating to patients. There is usually a snowball effect as they “get it”. When you monitor these areas, if you see slipping back from the “self-care” routines that can become an early indicator of relapse. “Self-care” routines clearly add a buffer of prevention.
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