Every now and then, someone comes into one of the support groups I attend or encounters me online and talks about how their family has decided to apply tough love. They are not alcoholics nor do they use illicit drugs. The parents or spouse are reacting to symptoms — usually the lack of motivation to exercise, take care of themselves, etc. The helplessness of the patient does not matter to them. They may not understand that it takes time to recover from a mood disorder or they may deny its existence. If you’re now taking medication, you should be better now, right? Or maybe they think it is time that you “got out into the real world”, suffered what “everyone” else suffers.
So they apply a philosophy that they heard about — maybe from friends, maybe from a therapist, maybe from Bill Milliken’s 1968 book or one of the many self-help guides that have replicated the idea which is called Tough Love. At its best, it is merely setting good boundaries — “sorry, but if you are going to use the money I give you for food to buy street drugs, I am not going to subsidize you”. But in American culture, it too often means employing cruelty to be “kind” whenever the patient doesn’t act in a way that the caregiver doesn’t like. And many caregivers make the mistake of thinking that the symptoms of the disease are something that the patient can control. You are depressed, they might reason, because you don’t exercise You are sleeping all day because you are a lazy good for nothing.
When they apply tough love in this situation, they are abdicating their responsibilities as a parent or a spouse. First of these is to understand the illness. Psychiatrists, for example, see the lack of motivation to exercise less as a cause than as a symptom. Studies show that exercise doesn’t do a lot to pull people out of depressions. A systematic review of the literature on exercise’s effect on depression found:
Exercise is moderately more effective than no therapy for reducing symptoms of depression.
Exercise is no more effective than antidepressants for reducing symptoms of depression, although this conclusion is based on a small number of studies.
Exercise is no more effective than psychological therapies for reducing symptoms of depression, although this conclusion is based on small number of studies.
The reviewers also note that when only high-quality studies were included, the difference between exercise and no therapy is less conclusive.
Attendance rates for exercise treatments ranged from 50% to 100%.
The evidence about whether exercise for depression improves quality of life is inconclusive.