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3. Building Social Competence and Interpersonal Connections
Many patients like Mark become increasingly isolated, even with the "gold" standard of modern psychiatric treatment. While Mark's friends have either remained in university or graduated and found regular employment, he spends most of the day alone without the usual social interactions that most people experience and take for granted. Mark's social network disintegrated as a result of his mental health struggles. Mark's only regular social interactions involve his parents and the weekly ACT team visits, during which his case worker seems more concerned about medication compliance than Mark's emotional and physical well-being. Mary, on the other hand, is not socially isolated, since she is married and has full-time work. Even though she is dreadfully unhappy, she derives benefits from full-time work and having regular interactions with people.
Spending too much time with oneself can escalate mental distress while also eroding important social skills. Some of the most common consequences of social isolation are loneliness and boredom. One study found loneliness to be associated with all mental disorders, particularly depression, phobia, and obsessive-compulsive disorder.40 Recent research has shown that boredom is correlated to depression and likely manifests in two forms: apathetic boredom and agitated boredom.41 I have observed in clinical practice the negative impact that loneliness and boredom have upon socially isolated patients, especially those who live on their own and receive disability support. Most of these patients lack a regular routine and a daily schedule. If social isolation is not managed aggressively, it can eventually lead to an early death when patients enter their fifth decade of life.42 Only through interactions with other people can patients develop the necessary social competence and skills required to foster meaningful relationships. Social experiences teach patients about themselves through the implicit and explicit feedback that they receive to help them develop the necessary social skills and competence and maintain solid relationships over their lifetimes.
To assist patients in overcoming their social isolation, I work with them to develop a weekly routine that keeps them busy while also providing important social challenges. Patients should be encouraged to volunteer and participate in library groups, reading clubs, adult education, and regular physical activity (e.g., walking or running groups/clinics). Most patients live in a community with a library and a community center and thus they have easy access to regular social events in safe, nonthreatening settings. Those can help to build social competence and maintain interpersonal relationships.
Since many patients develop social anxiety disorder as a result of their isolation, I refer them to Toastmasters (www.toastmasters.org) when appropriate. It builds confidence in public speaking and helps patients become more socially competent while working through their social awkwardness. In an article discussing alternative psychotherapeutic approaches for social anxiety disorder, Toastmasters was highlighted as an alternative that provides positive social exposure while fostering confidence in public speaking.43 Since many patients feel nervous being around other people, working on their public speaking skills in a no-pressure setting pays huge dividends with respect to their social competence and confidence over time. One of my patients with schizophrenia became so engrossed in the Toastmasters experience that he ascended the ranks and became the master host of his local group. The experience helped him make friends with other members and following the weekly meeting, he would often tell me in delight about the fun that he'd had at the local pub.
4. Getting Support
Patients need to feel supported by their peers and not just from clinicians providing care. Some of my favorite resources include 12-step groups (e.g., Alcoholics Anonymous and Emotions Anonymous), peer groups (e.g., Hearing Voices Network), and/or specific mental health support groups (e.g., Toronto Shyness and Social Anxiety Support Group). The majority of these resources are free and provide excellent support. They open up the possibility of creating lifelong friends or at least a consistent social network. Something extremely meaningful and therapeutic often happens when a person with lived experience connects to another person for similar reasons. This support reduces mental distress signals and helps patients remain focused on their wellness while also forging important social connections that provide a sense of belonging, the feeling of not being so alone, and community.
5. Engaging in Purposeful Work
For many patients, the idea of working has not been mentioned by their clinicians, since the visit focuses predominantly on their mental symptoms. Our patient Mark does nothing all day, and yet, with the right support, he is capable of securing regular work. He just needs someone to motivate him without focusing on his lack of self-worth and his mental distress. Mary, on the other hand, has a full-time job, but she is on thin ice since she has become impersonal and detached from her coworkers. With the right support, Mary could learn to socialize better at work. That might help her to relax and feel less anxious, and perhaps she might find work enjoyable again.
Like all people, patients need to feel productive through regular work and develop a sense that they are contributing to society. This work does not need to involve money, but it needs to be regular and it needs to provide enough of a challenge that the job does not become mundane and boring. Regular work should not be overly stressful or too difficult; otherwise, it becomes another trigger of mental distress. In other words, work needs to strike a balance between something challenging (but not too onerous or stressful) and something achievable (but not overly boring or mundane). A life coach or career counselor can help patients figure out what work or volunteer positions are most suitable for their needs. Free career counseling is often available if patients are motivated. When patients secure the right type of part- or full-time employment and/or regular volunteer work, their symptoms improve and they feel an increased self-confidence and mastery over their problems.
6. Developing a Self-Management Strategy
Self-management denotes the ability of a patient to pursue an active wellness plan, to recognize his/her mental distress signals, and to have a plan in place when things begin to go awry. The best way in which patients can do this work is through a program called the Wellness Recovery Action Plan (WRAP; www.mentalhealthrecovery.com), designed by Mary Ellen Copeland, PhD, a Vermont psychologist who has lived with and recovered from mental illness herself. Copeland developed WRAP for patients with mental health issues. It has approximately 20 citations indexed in PubMed. When patients complete this self-management tool, they end up with a package of self-help planning and coping strategies, which include: (1) a wellness toolbox; (2) a daily maintenance plan; (3) the identification of triggers and an associated action plan; (4) the identification of early warning signs that things are breaking down and an associated plan; (5) crisis planning; and (6) postcrisis planning.44
Research unanimously supports this approach and found that when patients do this work, they learn more about recovery and develop improved self-awareness by integrating WRAP into their daily lives.45 Engaging in WRAP leads to positive changes in patients' knowledge, skills, and attitudes toward recovery. This often inspires and empowers them and can even be life changing.46 WRAP has been subjected to formal studies that have shown it to reduce symptoms of anxiety and depression, and psychiatric symptoms in general.47,48 Even among patients with severe and persistent mental illness, WRAP was able to enhance hope, improve quality of life, and reduce psychiatric symptoms.44
Patients can pursue WRAP on their own by purchasing books and completing the required exercises individually and/or with the help of a social worker, case worker, friend, or family member. Patients can also enroll in a WRAP course, which is my preference, since it motivates them to take an active role in their recovery while also fostering social connections with people who have similar lived experiences.
Therapeutic Lifestyle Changes
Traditional therapeutic lifestyle changes (TLCs) need to be incorporated into an overall recovery plan because adequate physical activity, sufficient sleep, a healthy diet, and abstinence from smoking and other substances of abuse all buffer against allosteric load.4 Dr. Roger Walsh has authored the most authoritative paper on this topic. He noted that the primary benefit from TLCs is that they reduce primary psychopathology, whereas the secondary benefits provide neuroprotection, reduce age-related cognitive decline, reduce neural shrinkage, and improve physical health, self-esteem and quality of life.49 Walsh's review of the literature shows that TLCs can treat multiple psychopathologies while bolstering psychological and social well-being, and stabilizing and optimizing cognitive capacities and improving neural functions. Here I will summarize some of the key findings from Walsh's paper and explain why they need to be part of every patient's recovery plan.
1. Regular Exercise
Exercise favorably alters serotonin metabolism; improves sleep; increases endorphins (e.g., the "runner's high"); enhances self-efficacy and self-esteem; interrupts negative thoughts and ruminations; reduces psychosomatic muscle tension; increases cognition; increases brain volume (i.e., both grey and white matter); and improves vascularization, blood flow, and other functional measures.
If you recall, Mary only exercises once each week or less often, and Mark does not exercise. Both patients would find that exercise usually helps moderate symptoms while enhancing the quality of life. It appears that neither of these patients was encouraged to exercise by their conventional care providers, or exercise was not a focus of their treatment. It should be, since the positive effects of regular exercise cannot be disputed. In my clinical practice, I negotiate with patients on how often and how long they should exercise. Optimally, I would like them to exercise aerobically for 30 to 60 minutes every day or every other day, but for many this is not possible. It is important that exercise be presented like any symptom-moderating treatment. Patients need to be properly informed about the value of consistent exercise throughout their lifetimes. Some patients can only manage 10 to 15 minutes 3 times each week, while other patients can engage in lengthier and more frequent exercise. The goal is to motivate patients and encourage them to find joy in exercise and moving their bodies. I have found that something clearly shifts in a positive direction when patients become regular and avid about exercise.
2. Diet Modifications
Many patients do not understand the value of eating well and its potential symptom-moderating effects. The clinician should discuss diet and encourage patients to modify their eating to include: (1) lots of multicolored fruits and vegetables (a "rainbow diet"); (2) some fish, preferably cold deep-seawater fish that is low or without measurable levels of mercury (e.g., wild salmon); and (3) fewer excessive calories (i.e., eliminate or significantly reduce high-caloric nutrient-devoid foods such as processed foods and junk foods).
Research has shown that mood can be improved if diets are nutrient rich, especially if supplemented with minerals.50 A diet low in sodium and high in potassium was shown to improve overall mood, and to specifically improve depression, tension, and vigor.51 Overall, an optimal diet should be as close to being pesco-vegetarian as possible, since this helps to prevent and possibly ameliorate psychopathologies across the lifespan. This type of diet is nutrient dense and contains lots of potassium.
3. Connecting to Nature
Patients need to be encouraged to spend more time outdoors and in natural settings. Spending too much time in cities and densely populated areas impairs the ability of the perigenual anterior cingulate cortex to inhibit activity in an overactive amygdala. An overactive amygdala contributes to increased stress and psychiatric symptoms.52 Patients who only have limited access to nature risk developing disturbances of mood, sleep, and diurnal rhythms, as well as short-term impairment in attention and cognition. No pills can mimic the beauty and vastness of nature. Spending time in natural settings enhances cognitive, attentional, emotional, spiritual, and subjective well-being.
4. Limit Media Immersion and Hyperreality
Many of my socially isolated mentally unwell patients like Mark spend too much time on the Internet. Instead of interacting directly with people, they use the Internet as their only connection to people and the larger world. Mary has a different issue, but it is no less damaging to her psychiatric status. She does not stop working and she often uses her access to the Internet to continue her full-time job after dinner. Excessive media immersion is associated with psychological dysfunctions (i.e., "techno-stress") that include disorders of attention, cognition, overload, and addiction. Many of my socially isolated patients have unfortunately been "fueled" by the Internet and developed pathological gambling and/or pornography addictions. Clinicians need to discuss this with patients and educate them on the value of limiting Internet exposure, since this simulated reality can become more real to patients than actually living in the nondigital world. Patients need to understand the psychiatric implications of spending too much time on the Internet and not enough time with real people in real life.
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