What Is the Upstream Parable and Why Is It Relevant for Our Well-Being? Part IIRobert Brooks, Ph.D.


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In last month’s article I described the Upstream Parable. A main lesson to be learned from this parable is that it is far more effective to devote our time and energy identifying and addressing the causes of a problem upstream than constantly and frantically attempting to cope with the consequences of the problem downstream.

The benefits of a shift from a reactive, crisis intervention approach to a proactive, crisis prevention framework may seem obvious. However, many individuals and organizations become so overwhelmed extinguishing one fire after another downstream that adopting an upstream perspective is not even on their radar. Last month I shared how I and my staff at McLean Hospital embraced a self-defeating, negative script that perpetuated the problems we had with our patients. As my colleague Sam Goldstein and I observed in our book The Power of Resilience, while many people and organizations recognize that what they are doing is ineffective or counterproductive, negative scripts persist.

I’ve been asked, “Why are negative scripts so prevalent? Why do they continue even when we are aware that what we are doing is not working?” The answers may differ from one person to the next. One major reason is found when we adhere to the unwavering belief that our position is the “correct” one and that other people must change first. It is as if we expect at some point these others will experience an “ah-ha” moment and acknowledge they have “finally seen the light and will change.” That situation is not likely to occur. Another notable reason for adhering to the same ineffective script is housed in the belief that abandoning our script is the equivalent of “giving in” to another person or viewpoint.

As noted in my April column, many have asserted that the Upstream Parable received its greatest audience through a publication authored in 1975 by John McKinlay, a medical sociologist at Massachusetts General Hospital and Harvard Medical School. McKinlay applied the lessons of the parable to the healthcare system. His article was reprinted in 2019 and has been recognized as a classic.

McKinlay lamented that the healthcare system was dominated by a system focused on “downstream behaviors” that represent “short-term” solutions, advising, “We should somehow cease our preoccupation with this short-term, problem-specific tinkering and begin focusing our attention upstream, where the real problems lie.”

Lifestyle Medicine and Remaining Upstream

McKinlay’s emphasis on the healthcare system prompted me to consider once again one of my favorite questions, namely, “What are the intentional, preventive steps we can initiate to bolster our physical and emotional well-being and lessen the emergence of health issues?” Although intellectually most of us are aware of behaviors we can incorporate into our daily routine that will enhance our lives, doing so can prove to be a Herculean task.

I addressed this challenge of engaging in healthy lifestyle choices in two columns I posted in 2011, one in November and the other in December. In those writings I cited an article published in the American Psychologist 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 was titled “Lifestyle and Mental Health.”

Walsh spotlighted the concept of therapeutic lifestyle changes (TLCs), emphasizing that in many instances TLCs can be as effective as psychotherapy or medication in treating different medical and mental health disorders. He recommended that clinicians pay increasing attention to assisting patients to engage in TLCs, both to prevent the occurrence of disorders and to minimize their potency should they appear. Walsh identified eight activities that represent TLCs—activities that he viewed as being within our power to control (please see my November, 2011 article for a description of the eight).

My interest in what Walsh called TLCs began well before I read his article in 2011. Embracing a healthy lifestyle for physical and emotional well-being was already part of the focus of my work and closely associated with the concepts of personal control and a resilient mindset. I noted in last month’s column that when I first read Walsh’s article, I was unaware that seven years earlier the American College of Lifestyle Medicine (ACLM) had been founded. I have learned much more about lifestyle medicine (LM) in recent years given my collaboration with the current president of ACLM, Dr. Beth Frates, a friend and colleague on the faculty of Harvard Medical School and the staff of Massachusetts General Hospital.

LM is defined as “a medical specialty that uses therapeutic lifestyle interventions to prevent, treat, and often reverse chronic disease.” Six main interventions have been identified and labeled the Six Pillars of LM. As I mentioned earlier, making healthy lifestyle changes can prove very challenging. Thus, before highlighting the six pillars, I think it would be helpful for those reading this article to consider the following guidelines:

Focus on making small gains rather than attempting to change everything at once. This may seem evident, but one issue I have often witnessed in my clinical practice occurs when people attempt to make major changes in their lifestyle within a very unrealistic timeframe. To do so often invites a prescription for disappointment and failure. One example was a man I saw in therapy who was anxious and depressed and had gained a great deal of weight over the previous six months. When we discussed starting an aerobic exercise routine, he actually spoke about starting by jogging five miles within a couple of days. We discussed five miles as a possible long-term goal and established realistic short-term goals that could lead eventually to the five-mile goal.

In addition, small gains may be represented by initially focusing on just one of the six pillars rather than attempting to address all at once. Small successes contribute to greater self-confidence and an increased self-assurance and willingness to confront the other pillars.

Anticipate possible obstacles and how to cope should these obstacles arise. In her book Rethinking Positive Thinking, psychologist Gabriele Oettingen outlined her technique of “mental contrasting.” She advocated that when we establish goals, we should also consider possible obstacles that may arise during our journey to reach these goals. Once this step is accomplished, she recommended that we identify the thoughts and emotions that might arise when faced with possible obstacles and how we will cope with these obstacles should they appear. This last step can be viewed as promoting personal control, that is, accepting that our path to success in different areas of our lives may not go smoothly, but if that is the situation we are prepared to respond to the inevitable setbacks.

Display self-compassion. The concept of self-compassion, of being kind to oneself, has gained greater awareness in the past couple of decades, especially through the writings of Kristin Neff on the faculty in the Department of Educational Psychology at the University of Texas at Austin. Self-compassion is an important ally in our quest to adopt healthier lifestyle habits.

Even with the best of preparation, however, setbacks are likely to occur. When they do, it’s important to replace self-critical remarks such as “I’m just not smart enough to do this,” or “I’ll never be able to become healthier,” or “Why can’t I stick with things to finally reach my ideal weight” with self-compassionate thoughts such as “What have I learned from this setback that I can use next time?” or “I know there are other strategies I can use and I will try them,” or “Even though what I did didn’t work, I’m going to continue, but I may have to set more realistic goals.”

The “Six Pillars” of Lifestyle Medicine

Having described these three guidelines, I would like to highlight the six pillars of LM. I could easily devote a separate article to each of these pillars. For additional information with specific recommendations for changing one’s lifestyle in each of the six areas, please go to the link above for the Six Pillars Booklet. In addition, I have provided the link to an interesting article with research findings about LM posted by Mayo Clinic Proceedings: Innovations, Quality, & Outcomes titled “Foundations of Lifestyle Medicine and Its Evolution.”

Whole Food, Plant Based Nutrition. A basic component of LM pertains to nutrition. Practitioners of LM strongly advocate a “diet that is rich in fiber, antioxidants, and nutrient dense.” A major source of this diet includes “minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds.” Although I have moved closer to this diet in terms of consuming fruits and vegetables and rarely eating red meat, I must admit that I still love a daily chocolate chip cookie!

Lifestyle Activity. As many of those who read my monthly articles as well as those who follow me on social media platforms know, I am a firm believer in regular exercise as a major contributor to our physical and emotional well-being. Devoting a half-hour or longer a day in a variety of aerobic exercises—e.g., running, brisk walking, swimming, biking, dancing, playing sports—has been shown to provide a noticeable boost to our overall health. And, remember, one can start small and build up to greater exertion.

Stress Reduction. Stress is unavoidable, but we now know that there are “upstream” steps we can assume to lessen the impact of stress downstream. Exercise, meditation, yoga, and practicing gratitude are but several activities. Another is engaging in “contributory activities,” that is, activities that enrich the lives of others. The latter activities serve to add purpose and meaning to one’s life.

Avoidance of Risky Substances. Tobacco and excessive alcohol consumption contribute significantly to chronic diseases and early death. The use of illegal drugs does the same. I am well aware it is not easy to stop smoking or lessen or eliminate alcohol. Fortunately, there are groups and interventions to assist in dealing with these problems. A helpful list is provided in the LM Booklet.

Restorative Sleep. We’ve probably all experienced at some point difficulty falling asleep or remaining asleep. When this becomes a regular occurrence it can contribute to many ailments, including depression, feeling sluggish, inattention, and irritability. Given the ramifications of poor sleep, increased attention has been directed to strategies to improve sleep. Activities to be avoided before sleep are excessive food or drink, especially caffeine, and the use of devices that produce blue light such as cellular phones, computer screens, and television screens. Although many people have televisions in their bedroom, watching TV in bed is likely to increase sleep difficulties for a number of them. Sleep is made easier in bedrooms that do not have TVs or devices with bluescreens.

Social Connections. I would add the word “positive” before “social connections.” Research related to lifestyles and resilience has identified positive social connections as a major foundation for our well-being. Unfortunately, while we are aware of this research, there is other research that has shown an increase in feelings of loneliness, which is a significant risk factor to our health and mortality. In my March article I discussed the death of my brother Henry and highlighted the power of a “community of caring.” The presence of even a few friends or family who serve as what the late psychologist Julius Segal labeled “charismatic adults,” adults from whom others “gather strength,” can lessen stress and strengthen resilience.

In the March article I discussed how connecting with others can be a daunting challenge and described what one of my lonely patients did to meet people. He attended book readings where he might engage people with similar interests as his. At one of the readings he met the woman who has now been his partner for more than 15 years. Others have met friends by volunteering for political candidates or favorite charities or through events at one’s place of worship.

Conversely, another very challenging task is to distance ourselves as much as possible from people in our lives who are toxic and contribute to our feelings of anxiety and depression. As a woman at one of my presentations said, “They are anti-charismatic adults, who suck the energy out of you and constantly put you down.”

Concluding Thought

The Upstream Parable applies to many situations in our lives. Its message challenges us to shift from a reactive to a proactive position, a shift that can strengthen our personal control and well-being. The benefits of such a shift far outweigh the difficulties we may encounter in moving to a clearer perspective upstream.

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