tonylala111: Motivation Elevation: Training the Clinically Depressed Client

Now that we are in the swing of 2016, we are no doubt observing what I refer to as “The January Effect”: an influx of new members in our Fitness Centers, eager to jump-start their resolutions.

As is the case with our current clients, the majority of them come to the gym by choice. A small percentage of members are there out of guilt or because a doctor has strongly suggested they take a step in a healthier direction. We see this with new members as well as our current clients. A few even decide to join a gym in an effort to stave of the typical feelings of holiday let-down, after all the excitement of the December season is over. Such depression is common, but in most cases will be temporary.

There are always a few, however, who seem to have been “forced” into the fitness arena. These are the individuals for whom exercise doesn’t come naturally, owing to a variety of circumstances. Upon engaging with these members, we might in our minds be considering them to be non-compliant, difficult, resistant, and of course, frustrating. What we may not realize is that these individuals just might be coping with clinically diagnosed depression.

As we have witnessed in our own fitness experiences, there is nothing quite akin to that endorphin high, brought on by facilitating the body’s natural ability to manufacture serotonin (the feel-good chemical). Its appearance is always welcome, fueling our energy systems and flooding our brains with the magic words “Dig deeper! Keep pushing! You can get through this workout successfully!” Endorphins improve our natural immunity and may even reduce how our brains receive pain. This generally leads to a sense of euphoria and a positive mood.

Imagine struggling through what you perceive to be a very challenging workout. Now, imagine that same scenario with a compromised serotonergic system, the process responsible for liberating serotonin, particularly within nerve impulses. Suddenly, it dawns on you that if there are no endorphins waiting to reward you upon completion of the grueling exercises it seems easier to give up halfway through. Unfortunately, in most cases of clinical depression, this is precisely what is taking place.

The constitution of the World Health Organization includes the following definition: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Furthermore, this organization expects that by the year 2020, depression will have ascended to 2nd place on the ranking of “Disability Adjusted Life Years”. For this very reason, research scientists and biological psychiatrists worldwide are studying optimal ways to manipulate the human serotonergic system with pharmaceutical drugs. Certainly, the plethora of medication available with a prescription is proof of their success in helping to treat depression.

Is taking a pill every morning “easier” for some individuals than the thought of walking into a gym? The answer is a resounding YES. Must treatment end with the last swallow of water and the meds before starting one’s day? Fortunately, this answer is a resounding NO. This is precisely where the role of a well-informed personal trainer comes into play.

A reason for pursuing methods of elevating serotonin levels in the body arises from an increasing awareness on the part of professional clinicians that happiness and well being are important, not just as entities themselves, but also as factors protecting against mental illness. Conversely, recent studies have indicated that negative emotions were associated with increased incidences of depression and suicide.

Since it is widely accepted, and has been clearly demonstrated and documented, that exercise is capable of elevating the brain’s level of serotonin, it seems logical to compare this effect with those elicited by pharmaceutical drugs. According to Time Magazine, "Molecular biologists and neurologists have begun to show that exercise may alter brain chemistry in much the same way that antidepressant drugs do — regulating the key neurotransmitters serotonin and norepinephrine.” In the United Kingdom, the National Institute for Health and Clinical Excellence published a guide regarding the optimal ways in which a physician may consider the treatment of depression. The guide recommends addressing mild clinical depression with various strategies, including exercise rather than antidepressants, since the risk–benefit ratio for antidepressant use in patients with mild depression has not proven to provide a tremendous benefit. Some scientists have been able to show a significant shift within the hippocampus region of the brains of individuals living with clinical depression, pointing to the potentiality of exercise boosting not only serotonin levels but the actual number of serotonin-releasing cells.

In response to psychological trauma or stressful experiences, an individual living with depression and/or anxiety typically exhibits an increased secretion of stress hormones from the HPA axis (the Hypothalamus, Pituitary gland and Adrenal glands. Regular exercise helps the body to lower the amount of these circulating hormones, leading to the individual’s experiencing a reduction in his/her depression and anxiety symptoms. The basis for this biochemical theory is fairly straightforward: exercise acts on the same pathway as the one being targeted by antidepressant medications in the more traditional treatment of clinical depression.

Patients who follow aerobic-exercise regimens see improvement in their depression — improvements comparable to what is seen in patients being treated with medication. One study found that 30-minute aerobic workouts performed 3-5 times times a week decreased the symptoms of anxiety and depression by as much as 50% in young adults. Furthermore, aerobic exercise appears to lessen the occurrence of severe depressive episodes.

Returning now to our new Fitness Center member, it behooves us to be vigilant and pay attention to signs and symptoms of individuals who may be suffering in this manner. Decreases in the body’s serotonin levels have the potential of creating an inability to think out and execute a well-developed idea or plan, such as a training program. When working with such a client, their situation often will present itself as a loss of patience, being easily upset or annoyed, and being unable to control impulsive thoughts and actions. When a clinically depressed individual does not wish to exercise, he or she simply will not engage; the brain is sending the signal to stay on the couch all day instead. Remind yourselves that this is not your doing but rather the illness dominating your client.

Developing an exercise program for a client who is living with a depression/ anxiety disorder is clearly going to veer of the usual path to which we are accustomed. Remain aware that several of the more powerful characteristics of such disorders (loss of interest, motivation and energy; overall fatigue; diminished self-worth and self-confidence; fear of movement; social anxiety) have the significant potential of interfering with participation in (and enjoyment from) exercise. Mood may also play a role in social behavior. Positive social support (such as the wonderful camaraderie found in many gyms and Fitness Centers) is one of the most studied psychosocial factors in relation to this disorder. An absence of social support is often correlated with higher levels of stress and depression. By encouraging other members to interact with your new client, you may be helping him/her to feel more comfortable socially, increasing his/her chances of slowly integrating as a member of the gym community.

When conducting an assessment prior to designing such an exercise protocol, help the new client take an inventory of his/her perceived barriers towards exercise participation. This may lead into a discussion about possible strategies that could assist him/her in overcoming these barriers (problem solving, activity planning, seeking social support, cultivating a sense of self-efficacy). Exercise has shown to possess the ability to enhance one’s self-esteem and body image, thereby alleviating negative social symptoms.

Empathy, validation, praise and encouragement are necessary during all phases of training, but especially when a client struggles with ambivalence or doubts his/her ability to accomplish a desired change. Providing regular progress feedback to such clients is important. Emphasize the short-term benefits after single exercise sessions: improvements in mood and anxiety, stress level, energy level, distraction of negative thoughts, and the ability to concentrate and focus more sharply. Helping the client set realistic and achievable goals, which lead to successful experiences, generally gives the client courage to persevere. A text message or brief email sent in between appointments can serve as an uplifting and encouraging reminder that you believe in his/her ability. Knowing that a trainer is waiting for him/her and is looking forward to the workout can go a long way towards feeling of self-worth and self-efficacy.

Over the next few months, think about greeting new members and potential clients with your heart and mind before your strength and education even enter the discussion. You just may discover that some individuals don’t care how much we know, but want to know how much we care.

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