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In last month’s article I highlighted the concept of “personal control” in relation to the lifestyle we lead. I reviewed research that indicated that while the genes we inherit can predispose us to a variety of physical and psychological conditions, including cancer, diabetes, high blood pressure, heart attacks, and depression, whether these illnesses emerge or to what extent they emerge iss more within our control than we might recognize. The point I advanced was that while we do not have control over the genes with which we are born, we do have the capacity to choose healthy lifestyle practices that can help to neutralize or minimize inborn vulnerabilities towards different illnesses.
I highlighted an article authored by Dr. Roger Walsh, a member of the faculty of the Department of Human Behavior at the University of California College of Medicine in Irvine. The article appeared in the American Psychologist and was titled “Lifestyle and Mental Health.” Walsh contends, “Lifestyle factors can be potent in determining both physical and mental health. In modern affluent societies, the diseases exacting the greatest mortality and morbidity–such as cardiovascular disorders, obesity, diabetes, and cancer–are now strongly determined by lifestyle.”
Walsh introduces the concept of therapeutic lifestyle changes (TLCs), asserting that in many instances TLCs can be as effective as psychotherapy or medication in treating different medical and mental health disorders. He suggests that clinicians should pay increasing attention to helping patients adopt TLCs, both to prevent the occurrence of diseases and to minimize their potency should they appear. Walsh identifies eight TLCs that involve exercise, diet, enjoying nature, interpersonal relationships, recreational activities, relaxation and stress management, spirituality, and service to others. An appreciation of and engagement with TLCs can improve the quality and length of one’s life.
I received a number of responses to last month’s article. Those who wrote endorsed the importance of TLCs but concurred with my observation that while TLCs were of notable value, they were often difficult to implement or to sustain. Awareness of TLCs does not always translate into taking action; my colleague and close friend Dr. Sam Goldstein and I have emphasized that many of us persist in adhering to “negative scripts,” that is, we engage in the same behaviors repeatedly even if these behaviors prove counterproductive. Modifying negative scripts can prove to be a Herculean task for countless individuals.
Control Beliefs, Social Support, and Physical Exercise
I had not planned to write a follow-up article to my November piece, but I decided to do so. My decision was based not only on the interest shown by many of my readers about the theme of my November article, but also because I just came across a very interesting article that is closely related to Walsh’s concept of TLCs. I an aware that reporting the findings of still one more study will not provide the impetus for many people to modify their negative scripts. However, similar to other topics about which I have written, my hope is that the information might prompt at least some individuals to initiate practices that eventuate in a healthier, more resilient lifestyle.
The study in question was conducted by Drs. Margie Lachman and Stefan Agrigoroaei, both members of the Psychology Department at Brandeis University in Waltham, Massachusetts. The research, which is posted on the website PlosOne, is titled “Promoting Functional Health in Midlife and Old Age: Long-Term Protective Effects of Control Beliefs, Social Support, and Physical Exercise.” (The following is the link to the article for those who would like to review the complete study: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0013297.)
Lachman and Agrigoroaei’s perspective resonates with the proactive stance advocated by Walsh as well as by Sam Goldstein and myself, especially in our book The Power of Resilience: Achieving Balance, Confidence, and Personal Strength in Your Life. Lachman and Agrigoroaei observe that many studies have investigated “risk factors in relation to functional health, but less work has focused on the protective role of psychological and social factors. . . . Given that functional health typically declines throughout adulthood, it is important to identify modifiable factors that can be implemented to maintain functioning, improve quality of life, and reduce disability.”
Lachman and Agrigoroaei undertook a longitudinal study, assessing more than 3,500 adults between the ages of 32 to 84 during the years 1995-1996 and 2004-2006. They pinpointed the influence of three protective factors–control beliefs, social support, and physical exercise–and found that a composite of these three variables “at Time 1 (1995-1996) was significantly related to functional health change.” The more that these factors operated at Time 1, the better one’s health during the following ten years, controlling for “sociodemographic, health status, and physical risk factors (large waist circumference, smoking, and alcohol and drug problems).”
Given the impact that these three identified protective factors have on one’s health, I would like to elaborate on each.
Control beliefs involve the same basic tenets housed within the concept of personal control. Lachman and Agrigoroaei define control beliefs as involving “the perception that one can influence what happens in one’s life and to what extent one’s actions can bring about desired outcomes such as good health. Stronger beliefs about control over outcomes are associated with better reported health, fewer and less severe symptoms, faster recovery from illness, and higher functional status.”
They emphasize that control beliefs “show a pattern of decline in adulthood, making older adults more vulnerable in terms of expectancies about their ability to affect their health. The sense of control is related to functional health, in part, because those who have a higher sense of control are more likely to engage in health-promoting behaviors, such as exercising and eating a healthier diet.”
The finding that control beliefs weaken as one grows older invites a challenge for health-care providers of how best to promote these beliefs in patients of all ages as well as in the general population since we will all experience some decline in physical and cognitive skills as we age. I believe that health-care providers would be wise to convey the following messages to their patients:
1. In most instances a deterioration of physical and cognitive abilities can be noticeably lessened or slowed by adhering to a healthy lifestyle that is supported by a positive, proactive outlook.
2. When a weakening of our abilities occurs, we should shift our focus away from that which we can no longer accomplish and instead expend our energy to identify and engage in new, manageable activities that will provide us satisfaction and may substitute, in part, for our former activities. In essence, this message posits that while we are not able to control a diminution of certain capabilities over time, what we can maintain control over are our attitudes about and reactions to these changes. This latter belief provides a basic premise for us to engage in new behaviors that are achievable and gratifying.
In describing social support Lachman and Agrigoroaei write, “Social interactions involve a combination of supportive and stressful experiences. High quality social relationships are those in which support is relatively high and strain relatively low.” They report that elderly who are isolated are more likely to display “disability, frailty, and higher mortality risk,” most likely influenced by stress hormones and inflammatory processes that are intensified by loneliness. “Moreover, those who have supportive relationships are more likely to reap the benefits of a more active, engaged, and healthy lifestyle.”
The challenge is how best to create environments filled with group activities that are characterized by friendliness, support, and easy access, even for those who are not accustomed to interacting with others. The presence of just one or two trusted friends can serve a salutary function, providing the nourishment of social interaction that is a lifeline for our health. Loneliness and isolation are major health hazards that in most cases can be addressed with the right approach.
The positive impact of the third protective factor, physical exercise, has also been well-documented and the subject of several of my previous website articles (e.g., please see my September, 2008 article). Lachman and Agrigoroaei observe, “Those who engage in regular exercise are likely to reduce or avoid disability due to the positive effects on, for example, cardiovascular and pulmonary functioning, bone density, and muscle mass.” While many use memberships in Ys or athletic clubs as their place of exercise, exercise can take place with little, if any, financial cost in one’s home or simply by walking/jogging in one’s neighborhood. As we shall see later in this article, exercise can also be accomplished with a friend, thereby enriching our social relationships.
In summarizing their findings, Lachman and Agrigoroaei observe that there are proactive, practical measures individuals can adopt to lessen or minimize a deterioration of one’s health. “The findings suggest that multifaceted psychosocial and behavioral interventions that target multiple components such as a sense of control, good quality social relationships with family and friends, and physical exercise in early adulthood and midlife have a dramatic protective effect in reducing disability and maintaining functional health and independence into later life, over and above the contribution of reducing physical risk factors.”
The “I Know I Should” Negative Mindset
While Lachman and Agrigoroaei, Walsh, and many others have identified and enthusiastically endorsed attitudes and practices that improve our physical and emotional well-being, as noted earlier in this article it can prove challenging to adopt and maintain these practices. I’m certain we have all heard the following “I know I should” refrains: “I know I should exercise more,” “I know I should eat healthier foods,” “I know I should get more sleep,” “I know I should spend more time with my family.” Those who ruefully express these “I know I should” pronouncements frequently become trapped within a self-fulfilling prophecy. They believe they have little, if any, control to replace negative habits with healthier behaviors and, consequently, they do not entertain the possibility that they can adopt a more positive lifestyle.
I have met individuals who were finally motivated to change their less than desirable lifestyle when confronted with life-threatening situations or illnesses, often questioning afterwards why it had to take a dramatic event to prompt them to action. Marty is an example of this dynamic. He was a business executive in his early 40s whom I saw in therapy. He had little time to exercise, eat nutritious meals, develop close friendships outside of work, or strengthen relationships at home. He led a frenetic pace that, most likely, contributed to the heart attack he suffered. He was very fortunate that he was quickly rushed to the hospital and had successful bypass surgery. After this scare, he heeded his physician’s advice to modify the way in which he was conducting his life. He joined an exercise group devoted to individuals who had experienced heart attacks, adopted a low fat, low calorie diet, and set aside regular time to spend with his wife, his teenage children, and friends.
Marty came to see me shortly after the heart attack to “help implement and maintain changes” in his lifestyle and to “process” the anxiety he experienced about coming close to death. Given his desire to “lead a long, healthy life,” to see his children grow into adulthood, and someday to play with his grandchildren, Marty was truly motivated to change. During one session, he observed, “If you had asked me before my heart attack if I could make the changes I’ve made, I probably would have said ‘no’ or rationalized that I was fine living the way I was. However, after coming close to dying I wondered why I hadn’t made these changes years earlier. In reality, I was a heart attack waiting to happen. I’m now feeling much better, much happier, much more productive, and much more in control of my life than ever before. The heart attack turned out to be a blessing in disguise.”
While Marty’s heart attack served as a “blessing in disguise” for him, for many individuals such dramatic events do not result in the kind of positive outcome that Marty experienced. Some are not rushed to a hospital in time, some die, while others suffer lifelong debilitating disabilities. Rather than rely on “blessings in disguise,” it is more judicious to assume a less uncertain, preventative approach that involves implementing lifestyle changes that minimize the occurrence of these life-or-death situations.
To facilitate these preventative measures in my clinical practice I typically start small and suggest to my patients that they begin by selecting even one area to address. Let us assume the area they choose is physical exercise. I then ask them to identify both short-term and long-term goals that are realistic and can serve as guideposts for change (e.g., to walk one-half mile five times a week the first month and increase the distance by another half-mile during each subsequent month until they reach their final goal of walking three miles a day five times a week).
Once goals are established, I ask patients to consider the obstacles and/or setbacks they might encounter in achieving their goals and what they believe their reaction will be when faced with these negative situations. The purpose of introducing the topic of obstacles and setbacks is twofold, both of which pertain to nurturing a sense of personal control and resilience.
First, when people identify and anticipate possible obstacles, they are in a better position to take proactive measures to lessen the probability of these obstacles occurring. For instance, my patient Melissa was concerned that if she initiated an exercise regimen by herself there would be many mornings that she would feel too tired to follow the program. “I think I would find too many excuses not to exercise.” In anticipating this obstacle, Melissa spoke with a friend who was also interested in exercising on a regular basis. Both women recognized that they would be much more likely to adhere to such a program if they were to do it together. They were correct in their assumption.
The second purpose, which is related to the first, is that when people reflect upon how they might think and react if certain obstacles or setbacks occur, they are better prepared to avoid negative mindsets and self-defeating behaviors. In my clinical work I have frequently observed that a setback becomes magnified when one’s first thoughts represent a victim’s mentality–a mentality that will lead people to give up on their goals. If a setback triggers such self-evaluation beliefs as: “I knew I couldn’t follow through. I’m just a weak person. I will never be able to succeed at this diet,” one can predict that successful outcomes in the future are not likely to occur. However, if people anticipate that this negative scenario may emerge, they can learn ways of short-circuiting counterproductive thoughts and replacing them with a more constructive evaluation such as, “If something goes wrong it doesn’t mean I’m a weak person. We all can slip up at times, but the important thing is to learn from this setback when facing another obstacle.”
The power of anticipating obstacles was illustrated by my patient Harry who was about to begin a diet free of sweets and junk foods but was worried that he might falter. I asked him, “What if you stuck to the diet for a couple of weeks and one night you decided to have a scoop of ice cream (one of his favorite sweets)? What do you think you would tell yourself if that happened?”
Harry replied in a resigned way, “I’m pretty certain I would say to myself, ‘another diet out the window.’ That’s what has happened during previous diets.”
I wondered how he would act if he said that to himself.
He answered, “I can tell you what’s happened in the past when I’ve cheated on a diet. I begin to lose confidence in myself to stick with the diet, I become upset with my lack of willpower, and ironically, I begin to eat even more sweets and junk food.”
I empathized with his past struggles, but then added, “What if you changed this mindset by changing the message you told yourself? What if you said, ‘I’ve done a pretty good job the last couple of weeks. I know that once in a while I may slip, but the slip isn’t too bad and I think I can avoid eating ice cream tomorrow.”
Harry said, “I would love to get to that point, but I wonder if I can.”
I offered realistic hope with the observation, “I think that by anticipating your possible thoughts and reactions to setbacks you’ll be in a better position to adopt a more positive response and be better equipped to display self-discipline and to think before you act.”
Harry welcomed this train of discussion. It provided motivation for him to consider and implement a rather creative strategy, namely, to designate one evening a week as “ice cream night” in which he was allowed to consume one cup of ice cream without it being considered a breach of his diet. Harry declared, “This will work much better since total deprivation is not for me.” Interestingly, there were some weeks when he didn’t even use an “ice cream night.” However, on the weeks that he did, he accurately believed that he was in control of his diet rather than feeling he had little, if any, control over his behaviors. This attitude permitted him to follow TLCs with noticeable success.
The Information Is There to Apply
Thanks to the effort of many researchers and clinicians we have become increasingly aware of proven practices that can improve our health, reinforce a positive outlook, and add years to our lives. As I have emphasized in this and my previous article, while even constructive change is not easy to undertake, I believe it is important for all individuals to appreciate that we have more control over our thoughts, attitudes, and actions than we may realize. I do hope that by avoiding a negative mindset, reinforcing a sense of personal control, and defining realistic goals and strategies we will be in a position to implement TLCs that will bring us health and fulfillment. The choice is ours to make.
My best wishes for a happy and satisfying holiday season.