Emotional and physical therapy

Do you ever have those moments where in a flash of insight you realise something so incredibly blindingly obvious that you don’t understand how it wasn’t already obvious to everyone? A value of “everyone” that of course includes all previous versions of you for the past [mumble] years. And yet… it seems like it’s somewhere between novel to you and a niche opinion that some people hold but that has failed to achieve mainstream acceptance.

Usually the explanation is that it’s More Complicated Than That and there are some major downsides, or other people don’t actually want the things you want and so don’t actually value the things you think are obviously valuable, or acting on the thing is too much work to be worth it, or things like that. If something occurs to you that is so obvious that other people must have thought of it, they probably have, and if it’s occurred to other people and isn’t widely known there’s usually a reason for that.¹

But also I’ve learned to trust these insights as pointing to something interesting even when they’re clearly not as good ideas as they seem when they occur to me. Even if they turn out to be entirely wrong, it’s productive to figure out why they’re entirely wrong, and more often than not they’re not entirely wrong and contain the seed of something useful.

Anyway, I figured out recently that we’ve mostly been doing therapy² all wrong.

Short version: I think the primary starting goal for therapy should, in most non-crisis cases, be that of improving your physical health, and of getting you to move more and to “exercise” in the broadest possible sense.

I think this has a couple of clear advantages over many other therapeutic goals.

Specifically, the big thing I want to point to is this: For most people, the constraints on doing more exercise are emotional. This is because emotions are the the feeling of wanting to do (or not do) things. If you’re not exercising as much as you intend to, or as would be good for you, that’s probably because you’ve got a complex set of negative reactions and a bad relationship with exercise.

If… only there were some sort of toolkit for helping you learn to work with complex negative reactions and improve bad relationships, huh? Something that took these problems you experience in your life, treated the feelings you had about them as valid, and said “OK, where do you think that comes from, and what can we do about it…?”

Importantly: The fact that it’s an emotional problem doesn’t mean it’s an irrational problem. It might be an emotional response to a practical problem. e.g. maybe you’re trying to do exercise that is too hard for you, or you don’t know how to do properly, or that you don’t enjoy. As a result, exercise sucks, and you’re having a negative reaction to that.

The point of applying the therapeutic process here is to identify the specific negative emotional response you’re having to exercise and figure out what to do with it. That might be a practical intervention, or it might be an attempt at an emotional shift.

Instead what most people do is treat this as a personal moral failing. They sign up for a gym membership and then they don’t go to the gym and then they feel guilty about not going to the gym, and this makes them develop stronger negative associations with exercise, and become generally avoidant about the whole thing because they’re just not the sort of person who exercises, right? Then we laugh it all off as a joke as if our collective trauma around exercise wasn’t a major societal emotional and physical health crisis.

I’m always tempted to blame school for everything, and I certainly think that’s part of this. Maybe therapists should be starting by asking about how your relationship with your gym teacher was rather than your relationship with your parents.

I don’t think this is quite right. I think it’s more likely that the way we handle exercise in school makes things worse for people who are not already inclined to exercise³, and there’s definitely a sort of gym teacherly attitude in how we tend to conceptualise forcing ourselves to exercise, but I think probably the problems start earlier than that and go more broadly than that into how we think about exercise altogether.

Fixing this sort of problem is, of course, another thing that therapy is good at.

Why exercise is so high leverage

So far I’ve talked about why therapy is good for helping you exercise, but I also think that exercise is good for therapy, and doing therapy to help you exercise more and better is likely to produce outsized impacts compared to many other topics you could take to therapy. There are a couple of reasons for this.

The big one is that exercise improves your mood. Ideally, in the moment, but even if it doesn’t in any given moment the aggregate effect of being in shape is very mood improving.

Yes I know this is incredibly irritating to hear, but it’s also among the most well established empirical results about mental health we have⁴, and if you’re anything like me it’s incredibly irritating to hear because it feels like unactionable victim blaming. I’m trying to make it an actionable tool you can use.

It is also incredibly tractable compared to many other things you might reasonably go to therapy about, because it’s something you can work on separately from your immediate relationships with other people - you’re free to exercise in more or less whatever way works for you, without buy in from anyone else.

This puts more of it under your direct control and gives you a much tighter feedback loop for developing the relevant skills, which sets you up very well for applying those skills in other areas.

As a result, you should expect that applying therapy to exercise will work pretty well, teach you skills that you can apply to other problems, and will improve your mood fairly directly. It’s as close to a general purpose therapy to make things better as exists.

Mini book review: Exercise for mood and anxiety

This idea is of course not original to me. When I started thinking along these lines, I did some googling and found the book “Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being” by Michael Otto and Jasper Smits.

I posted what I thought at the time was a fairly damning with faint praise review of the book:

I think this book is possibly the best possible book on the subject the authors could have written. Unfortunately the authors are extremely basic bitch CBT therapists mostly writing pre replication crisis, which puts a sharp ceiling on how good it can be. Nevertheless the book is... Decent.

Elizabeth topped my review:

I fact checked the book and found the exercise claims solid, but when I gave the book to 6 people none of them exercised more.

However she also reports having personally got useful things out of it.

Here’s her full review of the book which is much more comprehensive on the specific empirical claims than mine will be. Her verdict was that most of the empirical claims about exercise hold up well. I haven’t checked this but trust her judgement (and also don’t find many of its exercise claims particularly hard to believe). I’m more skeptical about a lot of its psychological claims, which smell of replication crisis type results to me (e.g. it’s got a whole thing about smiling that I suspect is fake).

Nevertheless, the book has a bunch of useful insights and I don’t regret (skim-)reading it. The two big things I took from it are:

1. Exercise is great training for being comfortable with the range of sensations you can experience in your body. In particular the state of having done cardio exercise has a lot of overlap with anxiety. This means that being familiar with how your body behaves in these situations makes the feeling of anxiety a lot more tolerable. More broadly, exercise is a great place to train discomfort tolerance - not in the sense of forcing yourself through it, but exercise has a lot of things that feel a mix of good and bad, and provides a safe⁵ environment to explore that in.

2. It is helpful to do exercise not for its eventual benefits of getting healthy etc. but for its immediate improvement to your mood. That is, you can exercise in a way that makes you feel immediately better, and if you make that your primary association with exercise rather than treating it as a thing you are virtuously doing for eventual payoff, you’ll find it a lot easier.⁶

I think there were a few other useful insights in it that I immediately forgot because they didn’t leap out at me in the same way, and I have a vague intention that I may or may not act on to go back through and take notes.

That being said, I don’t think it’s very surprising that it didn’t result in change. I think if you read it while actively wanting to change your exercise habits and consciously put it into practice and were previously not very familiar with CBT like tools, it’s probably a decently useful book, but I’d recommend reading it alongside an actually good book about habit formation - maybe Tiny Habits by BJ Fogg, which isn’t a CBT book and thus is much better at teaching CBT skills than most CBT books.

Similarly there’s a bunch of stuff about mindfulness in there, but I don’t think it’s actually going to help you learn mindfulness⁷.

I also don’t think the therapy bits are very good, but that’s because they’re CBT and I don’t think CBT is very good.⁸

What would a good therapy for this look like?

Basically I think the answer is a fairly straightforward Focusing type therapy, filtered with a fairly practical oriented problem-solving approach. I wouldn’t recommend anything that tries to dig deep into traumas or the like, just a quite direct loop of “What am I feeling? What should I do about that?” over and over again each time you get stuck from making progress.

This is partly because this is a good toolkit for this sort of very straightforwardly goal-directed therapy, but it’s also because Focusing, as well as a therapy skill, is a really useful skill for being better at exercise, and so combining the two is a great opportunity to learn it better.

Focusing is about paying attention to how your body feels (the “felt sense”) and articulating what you’re feeling and noticing how the bodily feeling of it changes, and using that to come up with highly specific descriptions that capture exactly what you’re feeling in a way that gives you a useful handle for working with it.

I explain Focusing briefly here, and my default recommended book for learning more about it is “The Power of Focusing” by Ann Weiser Cornell. It’s not actually a very hard skill to pick up the basics of though - you can probably already do it to some degree⁹, any sort of training in it is really about helping you notice and refine it, but that refinement is important.

Anyway, I’ve been doing Pilates for most of a year, and I’ve been finding I use a Focusing-variant skill in it a lot The specific experience is something like… finding the right muscle. There’s often a specific movement I have to do, and it takes me a little while of mentally rummaging around in the relevant body part until I figure out how to make it move in the right way.

This isn’t exactly Focusing. The difference is that although Focusing is about the body, it’s mostly about producing verbal descriptions of bodily states. When paying attention to the felt sense for an exercise you’re ideally taking verbal thought out of the loop for doing it. If you’re trying to get a particular foot movement working, you ideally don’t find yourself thinking verbally “OK, so the foot needs to be pointing that way, but without collapsing my arch inwards, so what I need is to engage the muscles in the outer foot more…”. You instead notice the problem and adjust the muscles directly based on how it feels and looks. It’s still a conscious process, but not a verbal one. You can use the verbal one as an aid

This difference is crucial, but once you recognise it, Focusing is a pretty good route to learning it, and I think learning it will also improve your ability to do Focusing.¹⁰

You probably need to couple the Focusing with some slightly more structured problem-solving and habit change work, but it pretty much boils down to having a habit of actually going “This seems like a problem. Have I tried solving it?”. Maybe coupling it with the methods from “Tiny Habits” is good here.

What would a good exercise regime for this look like?

Personally Pilates has worked really well for me. I don’t know how well this would generalise - it’s well suited to the specific physical problems that I’ve been trying to work on (mostly chronic pain related to hypermobility), but most importantly I can afford one-on-one instruction and have access to a really good Pilates teacher. If that also describes you, I can definitely recommend following in my footsteps - I do group classes once a week and one-on-one instruction once a week, but I did about a month of one-on-one instruction before I set foot in a group class.¹¹

But going straight from zero to a formal exercise program is probably a bit much for most people who are having the sort of problems that I’m pointing to. I only managed it because I was already in reasonable general shape, had the assistance of one-on-one instruction who could tailor to my current level, and had a very specific problem I was trying to solve (chronic pain) - historically I’ve been very bad at sticking to exercise.

I suspect a much better starting point is the following two exercises:

1. Go for a walk.¹²

2. Stand up. Maybe close your eyes. Notice where you feel tense. Wiggle it. Maybe stretch. Just sortof haphazardly move in whatever way feels good. If nothing obviously feels good, do something silly. Flap your arms wildly. Wiggle your butt. Pay attention to how it feels, do more of whatever you like, do less of whatever you don’t like. Do this for a couple of minutes.

Signing up for a gym membership can also be helpful, but you’ll probably need to do a lot of therapy and habit work to make sure you actually go to the gym. Once you’re there, you can do a similar level of messing around with it, finding out which machines and weights you like and what you like to do with them. Grab some small dumbells and try moving your arms around with them and see what feels unexpectedly difficult (but not painful), or otherwise interesting, or enjoyable.

Importantly don’t try to push yourself too hard. You’ll need/want to build strength eventually but it’s much more important to learn to enjoy exercise than it is to immediately push for stronk.

At some point once you’ve been doing you’re likely going to find there are specific things that appeal and that you’d like to be able to do. Try to generate a couple, mentally autocompleting prompts “It would be cool to be able to…” or “My body feels like it should be able to X and it’s frustrating that I can’t”.

For me, two that came up here were crow pose (supporting yourself on your hands only while in a sort of sideways crouch with your feet off the ground) and asian squat (being able to squat flat footed on the ground as a resting position).

I got to the point where I could sortof do crow pose and decided I wasn’t actively that motivated to continue right now (my focus at the moment is very lower body and leg strength), but I’m still working on asian squat and can now more or less do it, but I’m still working on strength, quality of position, duration, etc.¹³

Once you’ve got some of these, you can experiment with having them as goals. Use them to drive specific experiments in what feels good. e.g. as part of working on asian squat I looked up a bunch of exercises that build towards it. I even did some of them. Mostly I just put myself into squat and various squat like positions whenever I felt like it, or worked on a few specific forms when I was at the gym.

I want to be clear: This isn’t optimal goal-directed exercise. You’re not looking to build strength, or do the perfect push up, or whatever. You’re looking to expand the ways it feels good to use your body. That involves starting from where you are, and expanding outwards in ways that you enjoy, not immediately pushing yourself to do things the “right” way.

At some point that’s going to give you some very specific goal-directed work to do in exercising. For example right now I’m working on calf strength, because a physio looked at my problems and went “yeah the reason you’re having problems is your calves are tight, and the reason your calves are tight is that your calves are weak”. I don’t particularly enjoy calf exercises, but I don’t hate them, and it feels satisfying to work on them as a very specific goal that I know will improve matters for me.

Mini book(s) review: Alexander Lowen’s various nonsense

I’ve currently got three different books from Alexander Lowen on my in progress pile. They are respectively: Bioenergetics, “Depression and the Body”, and “The Way to Vibrant Health”.

They are, as with a lot of 20th century psychotherapy, a really frustrating mix of insightful, intriguing, and absolutely fucking terrible.¹⁴

Alexander Lowen is part of the Reichian descended schools of therapy. He calls his work “Bioenergetics” but as far as I can tell it’s just Reichian therapy with slight variations and, more importantly to him at the time, not being associated with Wilhelm Reich in the immediate aftermath of him being arrested by the FDA for selling “orgone accumulators”.

But at the same time, I’ve got a lot of mileage out of Reichian tools, and Lowen does a good job of explaining them and pointing out their link to depression.

I keep getting annoyed with Lowen and nearly stopping reading him, and then he comes out with a really helpful insight or describes a problem I have perfectly and I begrudgingly mutter “dammit that’s a good point” and keep reading. Part of why I’m reading three of his books at once is I started with Bioenergetics and dug down further on specific points I wanted to read more about, until I got to the really actionable bits. “The Way to Vibrant Health” is almost a pure exercise manual with a little bit of Lowen nonsense sprinkled in between, “Depression and the Body” is a mix of helpful framing material and sheer insanity, and “Bioenergetics” was a bit too far on the insanity side for me,

A recurring theme of his writing (which seems correct to me) is that depression, and most emotional problems in general, has a very physical manifestation (depression literally makes you tired), and that working with that physical aspect of it is often much more accessible than trying to figure it out intellectually or get to some deep emotional core of it.

Additionally, “The Way to Vibrant Health” seems like a reasonably interesting manual of exercises to work if you’re looking for something to get started for weird helpful body movements. I don’t know if they’ll “reduce muscular tension and promote well-being, allowing you to feel more joy and vibrancy” like he promises, but if you’re trying to integrate exercise and therapy, it seems like it might be worth seeing what the series of physical exercises recommended by one of the few schools that seems to make a really solid attempt at integrating the two.

I’m probably going to try working through the book myself, and will report back later if I do.

Some useful books

If you want to read more on any of the ideas in this article, the following books might be interesting or useful:

• Exercise for mood and anxiety by Jasper Smits and Michael Otto

• Tiny Habits by BJ Fogg¹⁵

• The Power of Focusing by Ann Cornell Weiser

• The Way to Vibrant Health by Alexander Lowen

They’re all generally good books that might be useful on this theme. They all have some caveats to my recommendation, but eh you can figure out what their good and bad bits are for yourself.

What now?

I doubt I’ve left you fully convinced by my thesis. That’s fine. I’m not fully convinced by my thesis. But I think there’s something here. I’m going to be exploring it more myself, I’d recommend you do too.

In the meantime though, may I recommend you stop reading, stand up, and move around for a bit. Try waving your hands in the air¹⁶. Maybe wriggle your butt. See how it feels.

1. There are numerous exceptions to this heuristic, several of which I regularly find myself in, but they’re not relevant here.

2. I’m using “therapy” in a fairly extended sense that may or may not involve formally involve a therapist - doing your own therapy is a valid route, and is mostly the one I’ve taken, with occasional external assistance.

3. You can tell that this is likely because this is also how school works for everything else.

4. Yes, I know this is not a high bar to clear.

5. If you’re not surrounded by other children who will laugh at you for being bad and subject to the whims of a sadistic gym teacher…

6. Certainly this tracks one of my most successful times of being able to self-motivate to do exercise, which is when I worked at Google, every time I was pissed off I would go to the gym and run on the treadmill, which would make me feel better. I did a lot of running during the brief time I was at Google.

7. I don’t have a good recommendation for this though. I learned mindfulness by reading the first chapter of The Mind Illuminated and then completely ignoring about 80% of that chapter and not reading the rest of the book. I’m not good at meditation.

8. It’s extremely uncharitable for me to characterise CBT as “Have you noticed your thoughts are bad? What if you had good thoughts instead?” but that is what it often feels like. Importantly, it doesn’t do a very good job of considering that actually maybe your thoughts were good all along and it was your situation that was bad. I’m quite sure that this is a thing that competently executed CBT by good therapists can handle just fine, but I also don’t think therapists start getting good until you hit the 95%-ile, and CBT seems to attract a subpar quality of therapist because of how boring and mainstream it is, so…

9. After all, it’s just Binary Search.

10. Historically a problem I’ve had doing Focusing is that it’s easy for me to start with a thought and pay attention to the Felt sense to refine the thought, but relatively hard for me to start from a felt sense that has no verbal content already associated with it. I haven’t fixed that yet, but I’m hoping/expecting that working directly with the body in this way is going to be helpful for it. If nothing else, it expands your vocabulary of how to describe a felt sense because you can describe it in terms of the movement.

11. I can generally recommend this as a pattern whenever you start a new physical skill if you can afford it. Being a beginner in a group of people, many of whom either already know more or are learning faster, is the most stressful thing about this for me, and having a bit of one-on-one education in advance helps immensely.

12. You may find it helpful to imagine this eagle as you do.

13. I think one difference here is that I want to do crow pose because crow pose looks cool af, but I want to do asian squat because it feels like my body is supposed to be able to do it and can’t.

14. In particular, it’s full of very Freudian weird sexual obsessions, and he has terrible opinions about homosexuality.

15. Or “Atomic Habits” by James Clear, or “The Power of Habit” by Charles Duhigg. My discord collectively refers to these books as “The Atomic Power of Tiny Habits”. I’ve personally read Tiny Habits and liked it, and Atomic Habits seemed decent but I didn’t read much of it. A friend whose opinion I trust reports that she’s read all three and that “Tiny Habits” is by far the most actionable of the three.

16. Ideally like you care a lot.