Off the Couch and onto the Treadmill: Reconfiguring Psychotherapy

I have been a psychiatrist for more than twenty-five years and was trained to use a bio-psycho-social model of evaluation and treatment.  My approach focused on every thought, feeling and behavior having some biological basis.  Therefore, the two obvious choices available for treatment were medication and psychotherapy.  However, the choices within these options are numerous. Which psychotropic medication and which psychotherapy?  Big Pharma with their concept of developing a different "mousetrap" made the medication option more art than science.  Even using evidence-based medicine and remission rather than response as a goal, drug choices are not so obvious. I find I approach things more for the prevention of side effects rather than the slightly greater effectiveness of one drug over another.  Providing pills will change the patient's biochemistry ("hardware"), but what about changing the "software"?  This is where therapy comes in to assist in erasing bad programs and putting the fun in dys”fun”ction.  There are more therapy options than there are drug options.  Therapies vary in their purposes, frequency of meetings as well as comprehensiveness. Some approaches focus on changing behaviors, others on thought patterns, others on problem solving and still others on expressing emotions.  A contemporary approach has to incorporate many ideas in order to telescope treatment and facilitate change.

 Exercise improves mental health.  It has been shown that there are changes in neurochemistry which can explain the benefits of exercise.  Whether it is an increased turnover of neurotransmitters or increases in factors that promote neurogenesis (BDNF, IGF-1, VEGF, and FGF-2) patients always feel better after exercise.  That does not mean they like to exercise; in most cases, when stretched for time, exercise drops off of the list of things to do.  Incorporating a contempory approach I thought: “Why not exercise with patients while doing therapy?”

This idea really is not that contemporary.  In 1976 Thaddeus Kostrabala,M.D. published a bookThe Joy of Runningin which he established aerobic activity for the treatment of mental illness.  John J. Ratey, M.D. in his 2008 bookSpark-- The Revolutionary New Science of Exercise and the Brain described the neurochemical changes that may explain the beneficial effect of exercise on mental health.  Kostrabala performed running therapy in groups or individually while outdoors.  I felt that this appoach had a loss of anonymity as well as a non-optimal connection with the patient. Five years ago I placed two treadmills facing one another in my office.  I do talk therapy for 45 minutes while on the treadmill, face to face with my patients. I would match their pace, which was at times challenging when a patient chose to run.

 There were discoveries I did not anticipate when I first started this type of treatment.  I found that through the maintenance of eye contact while matching the pace on the treadmill patients felt "barriers were removed."  Others reported that when they were walking they could talk more freely and their emotions did not take over.  I experienced this as a reduction in their emotional incontinence.  This process allows patients to have controlled relief in real time.  Another reported result is leaving the session feeling "accomplished," somewhat equivalent to “calories burned.”  Clearly this accomplishment further enhances the therapeutic alliance.

 I believe this approach can telescope treatment making the therapy more cost effective.  In addition the benefits of exercise on sustaining a chemical balance reinforces an overarching "corrective emotional experience."