In many ways, psychiatrist Wayne Sandler's office in Century City seems pretty typical: a comfortable chair, a sofa, a desk and a wall full of diplomas and certificates. But along one wall is something out of the ordinary: a matched pair of treadmills that face each other.
They are part of Sandler's unusual approach to mental health. For the last year, Sandler has had several of his patients work out on a treadmill with him during their psychotherapy sessions. The patients come to Sandler's office dressed for exercise. Then, during their 45-minute counseling sessions, Sandler and the patient run or walk on the treadmill at their own pace.
Dozens of research studies over the last two decades have established the mental health benefits of exercise, and even explored exercise as a treatment for depression and anxiety. Recent studies by Duke University researchers found that exercise can be as effective as medication in treating depression, and is associated with longer-lasting recovery.
But Sandler is believed to be one of the few therapists in the country to combine exercise and therapy at the same time. "This was one way to deal with both physical well being and emotional well being, simultaneously," Sandler said.
Although many mental health professionals see little harm in combining exercise and treatment, some question whether the practice is stepping over a boundary that could adversely affect the therapist-patient relationship.
"Is there a potential for a slippery slope?" asks Kate Hays, a Toronto clinical and sports psychologist. She says that therapy traditionally takes place in a formal office setting. By introducing something unconventional into that environment, there is the possibility for a relaxed standard in the therapy session.
Dr. James Lake, a Pacific Grove psychiatrist who chairs the American Psychiatric Assn.'s caucus on alternative and complementary therapies, said he had never heard of combining therapy with exercise in the way that Sandler does.
Research has shown an association between exercise and mental health, Lake said, but it can be hard to measure exactly how exercise is beneficial, since people who exercise also tend to be involved in other activities that promote well-being.
One other therapist who is combining counseling and exercise is Jane Cibel, a clinical social worker and personal trainer in Washington, D.C. Cibel guides her patients through a 50-minute workout session that includes strength training with free weights and cardiovascular exercise on a treadmill. Throughout the session, she engages the patient in talk therapy.
Cibel says the relationship between a therapist and a patient is similar to that of a personal trainer and a client. "If they're working out with a trainer, people are talking the whole time," she said. "I don't think I ever met someone who, after working out at the gym, was more depressed."
Sandler said his patients have been positive about the exercise therapy. Several of his patients have told Sandler that working out during the therapy makes him seem more like a "normal person," rather than an intimidating psychiatrist.
The benefits of his approach, Sandler says, go beyond the simple idea of combining two activities in the same time period. Sharing the experience of exercise with the patient can deepen the interpersonal connection between the doctor and patient and break down barriers that can interfere with the therapy, he said.
Sandler said he was aware of the "boundary" issues, and that was a prime reason why the treadmills are in an office setting. By performing the exercise in traditional surroundings, the therapy preserves those boundaries, while still maintaining the benefits of exercise, he said.
Walking or running outside, for example, might foster an inappropriate connection between the doctor and the patient, Sandler said, but it also has one other significant disadvantage: There is no guarantee of anonymity.
The approach is not right for everyone, Sandler acknowledged. Research suggests that exercise benefits patients with mood disorders, such as anxiety, but not necessarily other conditions. Sandler said he carefully chose which patients to introduce to the therapy.
Despite strong evidence linking regular exercise to mental well-being, exercise is still not a common treatment for mental health problems. Hays, the Toronto psychologist, said one reason exercise wasn't recommended more often by therapists was because "it takes a certain amount of effort and focus and willingness, and a lot of people feel that it is much easier to have a medication prescribed to them."