Updated August 16, 2023
What is "Emotional Wellness"? Just as the concept of physical wellness doesn’t necessarily mean that exercising and healthy nutrition will get rid of your diabetes or hypertension (although it sometimes will), an emotional wellness program won’t necessarily cure someone’s mood disorder. Such a program might, however, help prevent someone from getting depressed in the first place, or keep them from relapsing once their episode is treated.
When put into perspective, psychopharmacology and psychotherapy could be considered passive on the part of the patient. In most types of psychotherapy, many patients only engage in the therapeutic process during their weekly 45 minute session, while they remain caught up in their usual patterns the rest of the week during day-to-day living. When someone takes psychiatric medication, they often (mistakenly) believe that they don't need ongoing psychotherapy. They take their medication, and they don't actively work on changing patterns.
That being said, initiating mental health treatment is inherently active, and can be quite difficult, especially while struggling with a mood or behavioral disorder. It can be quite a difficult process to just find an affordable provider that you want to continue to see over time. Continuing to make appointments, and actually come to the appointments, can also be difficult for many people. But how effective can a treatment really be if it only happens 45 minutes out of the week?
It is the job of the mental health professional to encourage the patient to engage in activities outside of the session that contribute to lasting positive growth, but there is a surprising lack of psychotherapists that prescribe "homework" and actually hold their patients accountable for completing it.
Bio-Psycho-Social
We as psychiatrists are in the unique position of understanding mental illness psychologically as well as biologically. We’ve also been trained to understand the environmental and familial contributions to mental illness, as well as the importance of establishing and maintaining healthy relationships, developing a healthy sense of self, emotional support, and other aspects of emotional wellness. The term “Biopsychosocial” psychiatry comes up with varying frequency. The biological, psychological, and social spheres are all important in our work with patients. These areas are all interrelated, and helping our patients strengthen themselves in each of these areas strengthens them in the other areas. The best example is that of regular physical exercise contributing to improved mood and emotional wellness, and conversely, that when patients learn to value and take care of themselves, they exercise and become more active.
Adding the "Spiritual"
A fourth dimension is often neglected by our profession; that of the Spiritual. Just as the other three spheres are interrelated aspects of life, spirituality is important as well. The term “spirituality” is defined here as a sense that has to do with an awareness of one’s self as a part of a larger universe, the awe in what is known and what is not known, with or without a higher power. For an individual, spirituality may or may not include an organized religion. For many, spirituality is an appreciation of nature or the laws of the universe. However the individual person defines it, I believe that spirituality is an important fourth component that we must help our patients grow and maintain in order to have a full and balanced life.
The Clinician's Role
We must look at our roles in the broader sense of advocating for our patients’ understanding and utilization of methodologies that can address all four of these areas. Whether we ourselves prescribe medication and do psychotherapy or we split the treatment, it’s important that we provide our patients with a perspective that helps explain their mental illness and how it relates to their physical health, relationships, environment, and spiritual needs.
From there, it's easy to show them that the connections between these systems and mental health go both ways, and that enhancing these systems will improve their mental health. They probably need help and guidance in some of these areas, such as a nutritionist or fitness coach, family or couples’ therapy or workshops, or perhaps social skills training. They may benefit from consultation with clergy, getting more involved in church, or exploring volunteer opportunities with conservation organizations. Many of our patients have motivational issues and/or self-worth issues in the psychological realm that with treatment will improve each of the other areas.
Goal Setting
It is important to set goals early in treatment so that the medication, the psychotherapy, and the patient are all working in the same direction. This goal-setting puts in motion the creation of synergy in treatment. Toward the end of the initial evaluation, we summarize our goals for treatment and discuss the concept of bringing together what we’re trying to do with medication as well as with psychotherapy. I explain that the more the patient does between the sessions towards our goals (such as homework or reading) the less they will need visit me and the less medication they will need.
In addition, there is the concept that once we get in the swing of routine self-care and maintenance, then slipping out of healthy routines becomes an important early warning sign of relapse. The routines become a buffer, a layer of protection. Active, lifelong mindfulness and maintenance of our body’s needs becomes a new backbone or foundation for a life as healthy as we can make it. Of course that may include the need for lifelong medications for certain illnesses.
We want our patients to leave the office with goals. These goals may include reduction or elimination of depressive episodes or panic attacks, establishing healthy sleep patterns, understanding their emotions, improving self-esteem, and/or self-care.
"Homework"
What can patients do between sessions to add to the synergy? Lots can be done to help move them through the behavior change process (see graphic below) and increase success. Homework can be grouped into categories, and can be in multiple categories at once.
Monitoring: Journals, diaries, logs, check-ins that simply require that they report something specific. This can help raise awareness of patterns for appropriate targeting of therapeutic interventions, and grow the patient's dedication to treatment. This helps them to move from "Pre-contemplation" to "Contemplation".
Processing: Journals, diaries, logs, goal-setting, and check-ins that prompt the patient to process an emotion or thought pattern. This could be more structured, or barely structured at all. An example would be a CBT cognitive distortion journal, which actively guides them through the process of challenging a cognitive distortion. This could also be considered "Implementing". This helps them move to the planning stage.
Researching: Looking into how to realistically implement identified goals. This could be looking for a gym that is financially affordable and within easy driving distance, or finding a habit tracking mobile app that has the desired capabilities. This is an important part of the planning stage, and helps to set them up for success in the action stage.
Implementing: Activities that have patients practicing skills; either with structured activities (like a worksheet to challenge cognitive distortions), as needed (healthy communication), or building new habits. This is the action stage!
If using CBT, you can give homework assignments such as mood logs and relaxation exercises. There are books that help readers make their own relaxation tapes, CDs, or podcasts on mindfulness, which patients can listen to as much as possible every day. Let us further expand the concept of homework to include a comprehensive approach that encourages a total lifestyle change, in order to build a new foundation for life, which would include healthy nutrition, regular exercise, outdoor recreation, and possibly yoga or other body/mind work. It would also include regular attention to psychological maintenance, such as hobbies, creativity, challenges, attention to important values and priorities, and love.
There are also social needs which require maintenance. Repairing damaged relationships where possible, deepening current ones, and making new meaningful relationships require work and prioritizing. We can also discuss the importance of addressing spiritual needs. Establishing these new and healthy routines is hard work. Most of us are not taught how to balance our lives; other peoples’ needs, making money, and looking good often come before taking care of our biological, psychological, social, or spiritual needs. The goal of Wellness is doing what we need to do for ourselves on a regular basis as a priority in life.
Although not new anymore, many of these concepts are not widely utilized by psychotherapists:
A Bio-psycho-social-spiritual perspective
Setting specific goals for the future
Patients being active in working toward these goals between sessions
Establishing and maintaining balance and wellness in life
There’s much more that we can do to create synergies between the goals of psychiatric medications and the goals of psychotherapy. When we add to that dual treatment, we’re well on our way toward the patient taking charge of their life. In other Synergy articles I get into more details and ideas about how to create and enhance synergies to help move our patients forward.
Next issue: Synergies In Treatment: Medication Effects and Psychotherapy.