in: Health, Health & Fitness, Podcast

• Last updated: March 14, 2022

Podcast #741: The Exercise Prescription for Depression and Anxiety

If you went to the doctor about treating your depression or anxiety, you might expect to be written a prescription for Zoloft or Xanax. But if you went in to see Dr. Jasper Smits, he might write you a different kind of prescription, one that instructed you to take a jog around the block.

Dr. Smits is a professor and clinical psychologist, as well as the co-author of Exercise for Mood and Anxiety: Strategies for Overcoming Depression and Enhancing Well-Being. Today on the show we talk about why he likes using exercise as an option for patients who struggle with mood disorders, anxiety, and even general stress and anger, but don’t want to do talk therapy or take a medication. We discuss how exercise has been found to be as effective for depression and anxiety as medication (and of course has a much better side effect profile), why it works, and whether a particular type of exercise is better for particular disorders. We then spend the rest of the conversation digging into the catch-22 that surrounds depression and exercise: if exercise is good for depression, but when you’re depressed you don’t feel like exercising, how do you find the motivation to get going with it? We discuss strategies for starting and sticking with exercise that can help not only those who struggle with mood disorders and anxiety, but anyone who is looking to make physical activity a habit.

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Brett McKay: Brett McKay here and welcome to another edition of The Art of Manliness podcast. Now, if you went to the doctor about treating your depression or anxiety, you might expect to be written a prescription for Zoloft or Xanax, but if you went to see Dr. Jasper Smits, he might write you a different kind of prescription, one that instructed you to take a jog around the block. Dr. Smits is a professor and clinical psychologist, as well as the co-author of the book, Exercise for Mood and Anxiety: Strategies for Overcoming Depression and Enhancing Well-being. Today on the show, we’re talking about why he likes to use exercise as an option for patients who struggle with mood disorders, anxiety, even general stress and anger, but don’t wanna do talk therapy or take a medication. We discuss how exercise has been found to be as effective for depression, anxiety as medication, and of course, has a much better side-effect profile, why it works and whether a particular type of exercise is better for a particular disorder.

We then spend the rest of the conversation digging into the catch-22 that surrounds depression and exercise. If exercise is good for depression, but when you’re depressed, you don’t feel like exercising, how do you find the motivation to get going with it? We discuss strategies for starting and sticking with exercise that can help not only those who struggle with mood disorders and anxiety, but anyone who’s looking to make physical activity a habit. After the show’s over, check out our show notes at

Jasper Smits, welcome to the show.

Dr. Jasper Smits: Thank you. Thanks for having me.

Brett McKay: So you’ve got a book called Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-being, and you’re a psychologist, and you’ve taken a look at exercise, but you’re taking a look at exercise, the mental health benefits of exercise. I think most times when you see research about the benefits of exercise, it’s always in the physiological, how it helps your heart, your muscles… What led you down the path to exploring the psychological benefits of exercise?

Dr. Jasper Smits: Yeah, as I have been interested in getting good treatment to people with mood and anxiety problems, and as a psychologist, as you just mentioned, I’ve been a big fan of psychotherapy, trained in cognitive behavior therapy or CBT. I like the evidence for that treatment, and I’m heavily involved in the implementation of it locally, but also through trainings and so forth. And I also really appreciate medications, I think they have an important role in the treatment of mental health problems, anxiety and mood disorders. And when you take a look at how these two fare, they do really well. There’s a good evidence base for CBT, it produces strong effects. Same is true for medications, but as you could probably expect, a lot of people also don’t do very well with CBT or don’t do very well with medications. And even if they could, let’s say they have the right disposition to respond well to these interventions, they may not have access to it, to CBT, like, I can’t find a good provider, or they may not care for it.

Some people just don’t like talk therapy or they don’t like taking medications, and I think it’s up to us people who research these kind of interventions who are invested in getting good treatments out to people is to increase the offering. I’m really excited to see the expansion of digital health products, I think that’s gonna help a great deal, and when I think about what’s available and what should be part of the offering, I think exercise should be part of that. And exercise has strong effects for mood and anxiety disorders and the later problems, and I also think that exercise fits in well for people who come to see us. Most people, they come to see us obviously for symptom relief, and that’s for the medications and psychotherapy can really be effective. The most people actually come, not just for that, but they just want a better life, they want to increase their well-being, and I think exercise is part of that picture for most people.

If you ask people who are physically active, “What does it do for you?” People will say, “It improves my well-being, it makes me feel physically better, and the direction from physical health to mental health is there.” If you feel physically better, you often feel mentally better as well. And it’s been rewarding to be involved in sort of pushing this out as one of many available strategies for people who struggle with mood and anxiety problems.

Brett McKay: Alright. So the goal is to increase the offerings or the options for people who have some mental health issue. So let’s talk about exercise. In the book, you highlight a lot of research that talks about the mental health benefits of exercise. For example, what do we know about the benefits of exercise for mitigating or managing depression?

Dr. Jasper Smits: For depression, the evidence base is actually really pretty good, the gold standard for interventions is to do a randomized controlled trial, and that’s how we study drugs, that’s how we study psychological treatments, and when you look at those trials for exercise, they yield effects that are comparable to what we see in direct therapies and psychotherapy, so it’s good, it’s not as strong as these two established interventions, but mostly because there’ve been just fewer studies, so when you look at the size of the evidence base, it’s less, but when you look at the effects, it’s about equally effective. There’ve only been a handful of studies that have actually compared exercise to, let’s say, medications for psychotherapy, there are few in number, they’re small in size, but when you look at those exercise [0:05:34.3] ____ actually pretty well in terms of tolerability, drop out rates are about similar to those interventions and the effects are about comparable as well, so that evidence base is what gives us the comfort of suggesting this as a prescription for people with mild to modern forms of depression.

Brett McKay: And what about anxiety? Is there any research about exercise and anxiety?

Dr. Jasper Smits: There is and often I actually studied mostly in medical population, so anxiety among people who have a chronic illness and less so in the anxiety disorders, let’s say, obsessive compulsive disorder, panic disorder, post-traumatic stress disorder, evidence is growing there, but much smaller in number. But the findings that are out there today also suggests that the effects are really pretty good, and to where I feel comfortable making a part of the offering and say when I look at these trials and look at the effects, I think it shows that exercise does definitely better than doing nothing, and in many cases, also better than what is a reasonable control, like stretching or something else that is of a minimal intervention.

Brett McKay: I know the research is limited, but has any research been done about particular types of exercise being particularly useful for specific type of mood disorder? I guess the question, I mean like, do you prescribe like, okay, if you’re depressed, do cardio or if you’re anxious do yoga, is there anything like that, or is it basically just any type of exercise will give you benefits no matter your mood disorder?

Dr. Jasper Smits: Yeah, I think if we just stick with the evidence, and that’s never a bad idea, if we stick with the evidence, we’d say if you follow the Public Health guidelines for exercise, which is like 75 minutes of vigorous or 150 minutes of moderate intensity exercise a week, aerobic, with a combination of some strength training, put you in a good position to see the effects over a few months, and that’s… I’m saying that because that’s often the dose has been studied in these large randomized controlled trials, so that’s a safe bet, but I think we’re starting to see and some initial research here that an effective exercise prescription for people with any mood or anxiety disorder or whatever they present with is going to require that you really take into account their preferences in terms of what they would like to do and what they think they can do, as well as the targets.

And let me speak a little bit more about the targets, targets, I think about let’s take someone with a mood problem where you find that isolation, for example, is a big factor in their depressed mood, then an exercise program that involves social activity, so a group like exercise or exercise with a buddy is likely going to be more effective in getting them their effects than if they are exercising on their own, preference is to most people, particularly those who come to us who are inactive, don’t necessarily have a positive experience with exercise or a history with exercise, they don’t necessarily like exercise otherwise, often they will be doing it.

And so exercise, I often equate it with hard work, we’re running, running outside, running in the heat, running in the cold, and those are not the things that you wanna start with with someone who already is suffering from depressed mood and who has a hard time engaging in values based actions, and so much of the work upfront is really about getting a good sense of what it is that a person might be interested in doing and going over a list of different possible activities that count as exercise, and that’s often where you start, and so for some people that might be taking a yoga class, or for other people that might be taking up swimming, for others that might be playing tennis, any kind of exercise that is often different from aerobic, and that might be a really good starting point for people to start forming an exercise habit, and to also recognize that over time, that exercise habit might change, so as people get more comfortable with, let’s say a yoga activity and more comfortable with actually making that part of their weekly habit.

Tuesday mornings is an hour that I reserve for yoga and they may be more interested and willing and able to pick up or add another activity that may be a bit more strenuous, more strongly in aerobics, so they may go from an easy so-to-speak yoga to more of a power yoga, or they may find another class that’s available at the gym that they attend, and so I am a big believer in spending a good amount of time with people at the beginning to get a sense of what they think they might like, list those activities, and then time again to what the targets are for them, and then start building that exercise program over time, making sure that you stay flexible, that that program likely will change as people get more used to activity in general.

Brett McKay: So with a lot of mental health interventions, whether it’s talk therapy or drugs, and sometimes it takes a while before you see the effect… Totally. With cognitive behavioral therapy, it’s not something you… Oftentimes, you don’t notice it right away. Is it the same thing with exercise, does the benefit take a while, or once people start moving their body, do they notice a mark difference?

Dr. Jasper Smits: Yeah, I think it’s one of the beauties of exercise and particularly exercise for mental health, we often think about exercise for physical health, and let’s say we think about a weight loss as something that is going to take a while, and so the distance between starting the exercise or the activity and the desired outcome is a long time, and I think that’s actually also true for stable reductions in depressed mood, when you think about these large randomized controlled trials, they often go for three months and then assess where people are in terms of their depressed mood for that particular week. And then the follow-up period. But as I said, the beauty for exercises that most people, even if they don’t enjoy the actual activity, and that is the during the activity, they report it being difficult and challenging, they will report a nice reduction from how they felt in terms of stress, retention or depressed mood before the activity, relative to after the activity, so you get that immediate boost of like, “Hey, I did the exercise, that may have been really difficult, but man, I feel much better now than I did at the beginning”. And we use that usually has the hook to get people interested and curious about making this part of their regular habit, is pay attention to what exercise does for you that particular day.

 I usually tie exercise prescription to what is relevant to a person for that particular day, let’s say I take someone who gets really stressed by attending work meetings, and they have a big meeting on a Thursday… I might say, “Hey, this meeting is at Thursday at noon. Can we plan an exercise bout, let’s say in the morning, so that you feel the effects of exercise before you go into that meeting, fare better in that meeting in terms of feeling a bit more stress resistant, a little less reactivity during that meeting, so that at the end of that day you look back, you can say, “Hey, this really worked for me, like today, even though it was difficult this morning when I woke up and I decided to do that activity it paid off for me immediately, and that’s a reason for me to continue to do it.” And then as people get into that habit of doing this more over time, they will start seeing those more durable reductions in depressed mood or anxiety, whatever it is that they are seeking help for.

Brett McKay: Okay, so yeah, that’s an interesting point. Exercise, as you said, when you’re pitching this to a patient and saying, “Hey, is this might give you immediate benefits in the short-term,” and it can be a nice supplement to what we’re doing… The talk therapy as well. So I think, I’m sure. Imagine a lot of people when they’re coming to you, they want a quick fix, they know that it’s not gonna be a quick fix, they gotta do some work, but exercise, hey, this can do maybe something a little bit for you to keep you going.

Dr. Jasper Smits: I do think that’s one of the appealing parts of the exercise prescriptions that you can use it, and the short bout prescription, like one of the things that I do sometimes with my patients, it’s just the 10 push-ups, people who sometimes experience intense activation of stress or frustration and don’t really know what to do with that feeling and feel like all they can do is maybe act on that feeling in a way that’s ultimately going to be more harmful than good. Then something like 10 push-ups can be really helpful to allow people to shift their attention from that intensity to again, back to where they wanna be, which is to focus on what’s in front of them, whether that’s their work or whatever they were doing at that time, so the short bout can be really helpful for getting people to see those quick reductions and whether it’s frustration, tensions or sad mood, that allows them to stay engaged in a way that really works for them in the long-term.

Brett McKay: So we’ve talked about there are benefits. The research says there are… Do we know how exercise works in helping with mood disorders?

Dr. Jasper Smits: I think we have a lot of ideas of why it may work, and as a psychologist have been mostly interested in sort of the behavioral psychological mechanisms, and so one of the reasons why I actually started researching exercises because I thought in an intense form, and that is when you really get people to do aerobic exercise and they feel all kinds of bodily sensations, like racing heart, sweating, breathing faster, it can actually serve almost like something that we call Exposure Therapy, which is really effective with people who have anxiety problems, and that is… If you get people to do these quick bouts of exercise, they get to really see that even though it could be uncomfortable to see your heart racing or that you’re breathing faster, that you’re sweating, it doesn’t mean that it’s going to lead to disastrous consequences. People with anxiety sometimes are concerned that heart racing is gonna lead to, let’s say, a heart attack, or that breathing faster is going to lead to suffocation, so in that way, exercise can be a really effective way to deliver that kind of Exposure Therapy.

So we’ve thought, “Hey, maybe it’s… ” One of the mechanisms of exercise is what we call this reduction in fear or fear or anxiety sensitivity, the sensitivity to anxiety and the related sensation or building up people’s what we call the stress tolerance, the ability to withstand the stress and say like, “Hey, it’s there… Feeling it, I do have a tendency to want to push this away, but because I’m exercising and I have this experience, I know that I can actually stick with it and persist over time,” and that is a powerful mechanism for many anxiety and related problems. And so that may be what’s happened at the psychological level.

Brett McKay: And then I think also in the book, you highlight there’s probably some endorphins stuff going on, we all know about your body releases neurotransmitters when you exercise. And that could help too.

Dr. Jasper Smits: For sure. I think, does exercise affect the brain? The answer is for sure. And I think that question is particularly interesting for researchers who are obviously interested in figuring out the mechanisms of action for any intervention, the idea is that if we know how it works, maybe we can make it even better, or we can learn about new treatments if we figure out how exercise can improve mood and what are the different brain regions that are involved, perhaps we can develop new drug treatments that act on these brain regions, and so it can be informative from that perspective. I also think it’s helpful sometimes for patients and provider to know how it affects the brain because somehow knowing that it affects the brain makes the intervention for many more legitimate, it makes it a real intervention, and I haven’t found that research, it’s not my expertise, and my sense is that it is challenging to pinpoint where the action is, and I think in part, because it’s difficult to study, study of mechanisms of actions really require lots of assessments, lots of subjects to really figure this out.

I also think it is challenging because exercise works for so many different things, works great for mood and anxiety, it also works for all kinds of physical health problems, so most likely, exercise will have broad effects and also lots of different mechanisms at different levels of analysis, so it’s an important puzzle, I really like the work that’s being done in that area, but I do think it’s gonna take a while for us to really get some good insights as to where the action really is, but hopefully we will see it in the years to come.

Brett McKay: We’re gonna take a quick break for a word from our sponsors.

And now back to the show.

Okay, so your focus is, you know it works. There’s research to suggest that it does work. So your goal is, “Okay, what can I do to help my patients do this thing that I know that… Know could help them.” But the catch-22 with a lot of mental health issues, particularly depression and anxiety is that you typically are not motivated to do anything. So it’s like how do you get motivated to exercise, which a lot of people aren’t motivated to do anyways. And so you spend a lot of time in the book walking through strategies to overcome this obstacle. So let’s talk about this. Let’s talk about… First off the obstacle of depression getting in the way of exercise… What are the cognitive distortions that can occur with depression or even anxiety too, that gets in the way of people doing something that they know could help them?

Dr. Jasper Smits: Yeah, I think… Let’s go through a few, but the first is, this is not gonna work for me. A pessimistic outlook. And fitting with that is, this particular intervention doesn’t work with me. And perhaps there’s also some history of exercise that feels to the patient confirms that, “I’ve never liked exercise.” Or, “I’ve never really gotten the benefit of exercise like others have.” So that’s then a challenge for the provider. And I think it starts with first some education, and just briefly outlining what the effects of exercise can be, which I think is important for any kind of intervention.

But education alone is not going to do it. So ultimately, patients might appreciate knowing that it might work and it works for others, but they might still leave with this sense like, “Well, if it works for others, that’s great, but it might not work for me. I would have to see that for myself.” And I think that’s where it comes to experiential learning. So I usually set up basically, an experiment with my patients and hope that I can get them to be willing to try exercise for a short period of time, even like let’s say a week.

And the experiment is really to see if we manipulate exercise… So we give people to commit to some sort of exercise for that week. If it actually, does deliver or yield the kind of effects that they will be interested in. So now I go back to what I mentioned before, which is the target. So let’s say if someone with a depressed mood who also struggles with sleep. Well one of the powerful effects of exercise is improved sleep. So I might ask that person to say like, “How about we track sleep for the next week.” And just kind of a sleep rating in the morning. What was the quality of your sleep?

And what we can do is come up with what we think is reasonable exercise for you. And I’m saying just for a week… I’m not asking you to exercise for the rest of your life, or even for two weeks. For the next week, would you be willing on some of these days to engage in exercise and then see what happens with your sleep on those days. And we can just keep track of this… We’ll manage, where we track your exercise or your physical activity. We’ll also track your sleep. And then we can review those data together and we can decide whether this is something that works for you. And so that’s the set up.

Most patients will be intrigued and they’ll respond and say like, “Well, I can probably do anything for a week, but let’s talk a little bit more about what exercise might look like.” And then I think you have to go to preferences. And you can’t just send a person away and say like, “Hey, why don’t you go try this now.” You actually have to start talking about, “Well what might that exercise week look like for you.” So let’s think about this… Today’s Tuesday. I’ll see you again next Tuesday. What does your week look like? And what can we do in terms of an activity? Can we do something outside around you? Is there a club near? Is there a partner? Is there a friend who can do something with you? What kind of exercise history do you have? Do you remember an activity that you sort of feel like you can maybe try out for this week?

Is that walking? Is that something else that might come to mind? So it’s a lot of problem-solving, troubleshooting and brainstorming there in the beginning. To come up with a plan that is feasible the question I ask at the end, it’s like, “Hey, we’ve now discussed this, we have a week. You’ve said on two of the days, you’re going to walk for 20 minutes with your friend. You’re gonna do this on Thursday at 5:00 PM. You’re also going to do this Sunday morning at 10:00 AM. We have the places where you’re gonna meet your friend. We have the tracking system set up. This is gonna be effortful, ’cause it’s gonna be very different from what you’ve done in the past, and certainly what you did over the last few weeks. How likely do you think it is you actually will be able to do this?” And so if a person says, “You know, 70%… 80%.” I’m happy… That sounds pretty good. And I think that’s a good way to get this started. If it’s less than that, we have to go back maybe in that session or subsequent sessions to figure out what parameters we need to change to get that to a higher likelihood.

Brett McKay: And what’s interesting is the way you described that process. You’re not telling the patient to like, “We’ll just get motivated from within.” Find that from within yourself. You actually created with the patient the motivation that’s outside of them… You’ve set up a system. There’s a person. There’s a place. There’s a time. They just have to show up and do it. Nothing really is like… There’s hardly any internal motivation going on.

Dr. Jasper Smits: Yeah, I think that’s right. I think that if we just tell people go do it, we will see something that we also see in the literature, which is 40% of people report being inactive, even though they hear from their physician, “You should be physically active.” So just telling people to go do it, particularly, with something that’s effortful like exercise… And then particularly, also when you already struggle with mood is just a non-starter. That’s not gonna go anywhere.

So you’re going to have to work with a person to shape their environment such that they can actually be motivated to do this. So that exercise can go up to the hierarchy all the way to the top of things that they are motivated to do. I think a buddy system is really helpful there. And clearly what’s important is to build in the ongoing rewards. I want a person at the end of that exercise bout that they do, let’s say on that Sunday morning when they walk with a friend to talk to their friend about how it felt to exercise. What did you notice? How do you feel now relative to how you felt when you woke up this morning. And attend to those immediate rewards of exercise, ’cause… We’re all motivated to do something if we are rewarded for the activity.

And it’s our task as a provider to figure out where the rewards lie for exercise for people. And it’s gonna be different for different people. And that’s where you have to really have this conversation with the patient about, what is it for you and what do you think it will do for you, and can we set it up in a way to where you’re gonna see the positive effects of exercise for you. ‘Cause in the end, when we think about any intervention, whether it’s psychotherapy, where much of the focus is on skills training or drug therapy, where the prescription is long-term… Exercise too.

It’s not about getting a person to exercise for, let’s say two or three months and say like, “Now, you’re good.” With exercise it really is about getting a person from being a relatively inactive person to become someone who sees exercise and physical activity as part of their life. Something that they will do on a weekly or daily basis… Or whatever fits with their life. They will… Sees themselves as someone who’s physically active. And getting a person to that is just requiring that you start slowly and that you get a person excited about this in the sense that they see how this works for them and what benefits that has emotionally for them, particularly in the beginning.

Brett McKay: So what do you do with… Let’s say you’ve got a patient and you did that first week with them success, they’ve caught the vision and they’ve got this habit of exercise going… But when you’re working with… Through any type of mental health issue, you’re gonna have days that are… You have a setback. Because of increased stress, etcetera. How do you help your patients prepare for those setbacks so that whenever it comes, they still do that thing, that exercise that can help them?

Dr. Jasper Smits: Yeah. Yeah, I’m glad you’re bringing that up because nothing is linear typically in the treatment of mental health problems. It isn’t like you start at the bottom, so to speak, and then you in a straight line, move up to where you wanna be. Oftentimes, you see some improvements and then you see some dips and then some improvements, and then some dips again… Lapses or relapses, if you will.

And I think it’s so important to bring this up with the patients at the beginning, that even though we’re after initial successes and we are going to build on those successes together… And as a provider, I very much act like your coach… Much like a gym instructor or a fitness instructor. I know that they’re going to be times that your actions didn’t line up with your intentions. Like you had set out to go do this particular exercise, but something came up and you didn’t. Or something was really stressful when you said, “Hey, I’m all out, and I’m not going to follow through on this.”

And that’s real. And that’s going to happen. And setting it up as an expectation and also normalizing that, I think is just the beginning and… Because oftentimes in the dynamic with the provider is also this, I don’t wanna disappoint this person. And if I… I’m not really doing what we set out to do, well then maybe this intervention is not right for me. So anticipating this and making this something that is going to be part of that journey moving forward to become a physically active person… That is there are going to be times that it’s not working for you, is part of it.

And those times that it’s not working for them, just require more conversations with the provider. And that is like, “Hey, let’s talk about what happened.” And let’s talk about what explains that. And let’s pick up from there and see what we can do today to pick back up. And if that means, “Hey, you can start where you left off,” or we need to do something a little bit different, that’s fine. But that sort of flexibility that you have as a provider, but also from the patient’s side is what’s needed to be effective with this type of intervention.

Brett McKay: So it sounds like you’re doing cognitive behavioral therapy, and this is helping them exercise… So you have to like… “Okay, they didn’t do it.” Typically, people who are depressed, they have that catastrophizing, or like that… Well… The black and white thinking… Well, I didn’t do what I wanted to do, so I just shouldn’t do anything at all. And it’s all for nought. Instead you’d say, “Hey, well, you didn’t do what you wanted to do, but maybe you could just walk for 10 minutes and learn how to be okay with that.”

Dr. Jasper Smits: Yeah. Yeah, for sure. I think our CBT skills are really effective when it comes to exercise coaching and managing the exercise program and interpreting the effects and helping patients stay motivated, and attending to the cognitions, like you just said. What is it that you’re telling yourself right now? Or what are you telling yourself about exercise? Or what are you telling yourself about what’s gonna happen over the next week? And let’s take a look at that together and see if there are different ways of looking at this. And recognizing that oftentimes those predictions or the way that people talk to them are mood driven. They’re very different… How you talked about this, let’s say two weeks ago. And what does that tell us?

And addressing thoughts like that or talking about thoughts like that in that way opens up the possibility that patients can develop some flexibility and say like, “Man, I am really sort of stuck right now.” And I find myself… Like you said, back where I was before in terms of how to think about myself and this intervention. But you’re right, if I look back over the last few weeks when we did this effectively, this is how it worked. And perhaps what it takes is X, Y, and Z. And that’s an opening again for them to get back and start where they were the previous week. Or maybe dive into a different set of activities to continue their exercise regimen.

Brett McKay: You know it’s interesting, this stuff works, even if you don’t have a diagnosed mood disorder… This is actually just useful information or skills to have if you’re trying to implement any type of healthy habit, whether it’s exercise or nutrition. The same sort of thing, it works.

Dr. Jasper Smits: I think so. And I… As a psychologist, I work a lot with people who have a disorder, like a depressive disorder or an anxiety disorder… But most of the patients come to me and they’re not like, “Hey, can you help me get rid of this disorder.” Most people even though that’s obviously what they want, they really come to see us because they want a better life. And a better life is they wanna feel better about themselves, they wanna feel better about what the future has to offer for them. And all the things that they are involved in. And healthy behaviors are often a big part of that.

People tend to feel better when they’re physically active. They look at themselves and say like, “This is who I am.” I use my body. I noticed that that physical pain that I feel a little bit like in terms of, let’s say, a little muscle ache, that’s okay. That’s just a signal that I’m actually using my body and I’m being active. And the same is true as you said for nutrition. People tend to feel better when they’re eating more healthily than when they don’t.

Brett McKay: So let’s talk at another issue that springs up with patients when you prescribe-exercise for them. So maybe they know that they’re gonna feel good after it’s done, but when they’re doing the exercise, if particularly they’ve been inactive for a really long time, it doesn’t feel good while they’re doing it. ‘Cause it’s just… It’s uncomfortable, etcetera. And that can be… That can be un-motivating… The fact like, “Ah, this doesn’t feel good. I’m gonna stop.” So what do you do with patients there to coach them through that?

Dr. Jasper Smits: Yeah, I like you’re bringing this up. And I think it depends a little bit on the patient… Actually, for some people that not feeling good during exercise can actually be something that is important for their treatment plan. That is to say like, “What can we do actually for you to increase your tolerance of these kind of sensations, and that you actually relate to that type of distress differently?” We’ve done some work on smoking cessation and evaluated an exercise program for smoking cessation. But particularly, for people who go back to smoking after they quit because they don’t know what to do with those symptoms of withdrawal.

And when they experience that the first thing they do is they go back to their cigarettes because that’s how they manage that distress. And in those cases, we find actually it’s really helpful to do more of those intense exercises so that people can be more prepared to persist during the times of withdrawal. And so that then becomes a target. Patients then sign up to do that. And then it’s working with them to really learn to sort of accept those feelings and stay with the exercise.

And it could be little things. It could be that reminder of like, “Hey, this is why I’m doing this, and this is why I’m actually engaged in this kind of uncomfortable set of exercises.” It could be as simple as also practicing the half smile, which is like just notice or be aware of how you’re actually showing this kind of distress right now. Is there anything that you can do in terms of your posture or your facial expression that will actually have you relate to this a little bit differently.

That’s for a particular group of people, where the target really is to increase what we call distress tolerance. But for most people, like you said, exercise when it’s too uncomfortable and it’s really not a reason for them to engage in it… Like it doesn’t necessarily help them with their mood or anxiety goal, then we do figure out how to make the exercise a bit more interesting, engaging and less aversive. And so with very few people, actually, I start with intense aerobic exercise. I might work up to that with people, but oftentimes it is actually reducing that.

I am totally okay, for example, in the beginning of an exercise regimen, if we get people to just exercise very lightly, and to just monitor their heart rate, keep it fairly low. And so we say, “Let’s get used to this first, and let’s actually make sure that you progress in this training to where you feel like you can handle what is a bit more intense bout down the road.”

Brett McKay: And there’s another thing you do to is… As far as doing some problem-solving. If you don’t… If you feel uncomfortable doing it, like find out ways you can mitigate… Like, you’re still feeling uncomfortable, but it’s not as bad. So I guess an example, I thought of, like play a team sport. Do something with a group… For some reason, and whenever you’re suffering with other people it somehow weirdly reduces the suffering, and it kind of is motivating to see someone else is doing that. That might be another option as well.

Dr. Jasper Smits: Oh for sure. I like that suggestion a lot, that what are some of the ways in which you can make the exercise more tolerable. Certainly doing exercise with other people, for many will do that. If it’s a group exercise, for some actually makes it a little bit more challenging. Those people have, let’s say, social anxiety problems. They sometimes find it actually a bit more challenging to exercise with other people. But, yeah you’re right, you want to figure out ways in which people can engage with the activity to where it’s going to be a little bit more interesting.

So they will notice the activation, the physiological activation, yet that’s not all that they notice. They also notice their friend around them. Or if they’re alone, they will be listening to, let’s say, a book or a podcast. And you teach them to really engage with that as well. It’s like, what are you hearing there? So can do two things at the same time? Which is you are experiencing that distress, and at the same time, you’re also able to actually listen to, let’s say a podcast or listen to your favorite play list.

And so it is, again, personalized where you work with the patient to figure out, “Well, what does it take for you?” What would it take for you to be okay with the activation and also engage or notice the other things that are around you that are interesting and important to you as you participate in the physical activity?

Brett McKay: Yeah, it’s interesting you brought that up. Doing something that you enjoy while you’re actually like… We had Katy Milkman on the podcast a while ago about… Talking about temptation bundling. And she mentioned that. If you don’t like to exercise well, then you do something… You set something up where… Well, I can only listen or watch this movie that I really love when I’m on the treadmill… And then that can be a motivator to get on the treadmill or do whatever… Or take a walk, whatever.

Dr. Jasper Smits: I do that for sure for the exercises that I don’t particularly like to do. I do some strength training and I really don’t find it that interesting. Or it doesn’t feel very good. But it is the time that I listen to my favorite podcast. And it might take me a little longer to get through it, because I wanna listen to both the podcast, but I know that I get both in. Which is the podcast time and while I’m doing that I actually got that particular exercise or set of exercises done. And so I like tying activity to other rewarding activities, whether that’s something that you like to do for yourself or whether it’s something that you like to do with other people. And so look for those things that make it more motivating for you, and more likely that you actually get something out of it.

Brett McKay: So yeah, again, the goal is… Enjoy yourself. Don’t think of it just as medicine that you have to take. Make it something that you can enjoy, and can be a part of your life for the long run.

Dr. Jasper Smits: Oh, for sure. And I think that’s definitely what you wanna work and what we work toward with our patients. It may not be there in the beginning when we just set up those initial successes, but as we’re trying to build a habit… Like something that’s going to last over time, we do want it to be something that’s enjoyable. And to your point earlier, how do you anticipate the things that might change over time, that also will change over time.

A lot of people won’t like an activity for very long. They might like, let’s say running for a little bit, but at some point they get kind of sick of it. So you wanna stay flexible, anticipate that, and say over time your exercise regimen… The set of activities that you engage in might change and you’ll stay open-minded, and curious to other activities that you will use to replace the ones that you’re sort of bored with, or no longer find interesting. Or you develop new friendships. Or all of a sudden you’re exercising with your family. Like you might exercise with your kids, or you might exercise with your spouse. All these things that keep it interesting, and keep it something that is enjoyable over time, and stay flexible that it might take lots of changes along the way. And that’s where I think sometimes providers can be really helpful, is to stay creative, help troubleshoot and come up with ideas that people can implement to keep their habit alive and active over time.

Brett McKay: Well, Jasper this has been a great conversation. Is there some place people can go to learn more about the book and your work?

Dr. Jasper Smits: I think the book is just on Amazon, and that’s probably the best access for people to get a sense of how to think about exercise and how to incorporate it in their life as they have goals for improving their well-being.

Brett McKay: Fantastical. Well, Jasper Smits, thanks for your time. It’s been a pleasure.

Dr. Jasper Smits: Thank you, I enjoyed it.

Brett McKay: My guest today was Dr. Jasper Smits. He’s the co-author of the book, Exercise for Mood and Anxiety. It’s available on Make sure you check out our show notes an Where you can find links to resources where we delve deeper into this topic.

Well, that wraps up another edition of The AOM Podcast. Check at our website at where you can find our podcast archives, as well as thousands of articles written over the years about pretty much anything you can think of. And if you’d like to enjoy ad free episodes of The AOM Podcast, you could do so on Stitcher Premium. Head over to, sign up. Use code manliness, at check out for a free month trial.

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