Making Room for Play in Lifestyle Medicine

Abstract

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“Engaging in playful activities can reduce stress and improve mood.”

A reflection on the power of play, by one of the authors (FM):

The 2024 ACLM meeting in Orlando had many wonderful moments. But, Dr. Elizabeth Markle’s presentation on Community as Medicine left an impression like no other. “Find someone you don’t know,” she said. I looked around and there was a woman also sitting alone, looking around in that slightly forlorn way one does in such circumstances. We caught eyes and smiled and stepped towards each other.

“Now, we’re going to put on some music. One of you will be the leader and dance, and the other one has to follow and do whatever the leader does,” Dr. Markle said. The music came on. It was energetic, with a great beat. It made you want to MOVE. My new-found partner started doing some moves, and I tried to follow her. In less than 30 seconds, we were both laughing, dancing and having a great time. We switched and laughed and danced even more. Then we did a few sharing exercises, talking about what went well or not well in our day to that point.

Finally, Dr. Markle asked us each to think of someone who we knew really loved us for who we were. “What prescription for your life would that person write for you?” she asked. I looked around the room. Tears appeared on many of the faces I saw, including my own. I shared my prescription with my partner, now a friend through play. And as she wiped her tears, we both just looked at each other in amazement and said, “How did that just happen?” The answer is that once we got playing—dancing and laughing—the conditions were created to open us up to permit the magic of what was to follow. Play can have profound effects on group dynamics, on how we open ourselves to others and to ourselves. And in doing so, play can have profound impacts on our health.

This article intends to show how play can be integrated into our lifestyle medicine (LM) practice. The idea is not to add another pillar of LM, but instead to show that play is an element that fits within the spirit and pillars of LM. We will start by defining play and playfulness, and will then discuss the scientific evidence for the health benefits of play for adults. Third, we will share how to integrate play into our LM practice. Finally, we’ll give tips for assessing and amplifying play in our own lives as LM practitioners.

Defining Play and Playfulness

Play has been defined in many ways, both as a noun and a verb. It stems from Old English plegian (“to exercise”), plega (brisk movement), and is related to Middle Dutch pleien (leap for joy, dance). ¹ The National Institutes of Play defines play as “a state of mind that one has when absorbed in an activity that provides enjoyment and a suspension of sense of time. ² ”

Playfulness is the essence of play, the state that allows one to play. Henriot, a French philosopher who wrote extensively on the subject, characterized playfulness by uncertainty, illusion, and unpredictability ³ while Bishop and Chace use the descriptors exploration, freedom, and joy. ⁴ Ferland, another French scholar, characterizes playfulness by curiosity, spontaneity, pleasure, and a sense of humor ⁵ while Bundy adds freedom to suspend reality to the definition. ⁶ The importance of playfulness as a lens for how we respond to life’s events is also emphasized in Barnett’s definition: “Playfulness is the predisposition to frame (or reframe) a situation in such a way as to provide oneself (and possibly others) with amusement, humor, and/or entertainment. ⁷ ”

For the purpose of this paper, when we refer to play and playfulness we invoke all of the above, wanting to avoid a rigid definition. We recognize the paradox that play is usually done with an energy of spontaneity and fun (e.g., without specific intention or purpose) while also recognizing that play has incredible purpose in terms of its health effects. We will now focus on some of those benefits.

Health Benefits of Play

It is well-understood that play is an important part of a child’s development, a way to learn socialization skills, to learn about one’s body, and as a way to learn about the world. However, much less appreciated and talked about is the importance of play for adults. Some of this may be that adult play is shunned.

Is a lack of play bad for our health? Dr. Stuart Brown, a psychiatrist and founder of the National Institute for Play says, “The opposite of play isn’t work; it’s depression.” He adds, “The adult-play deficit is becoming a public health crisis. ⁸ ”

And as a corollary to the above question, “Is playing as adults good for our health? The answer, supported by various threads of research, seems to be a very firm ‘Yes!’”

Cardiovascular Health

Playfulness in adults is associated with improved cardiovascular fitness. A study found that self-rated playfulness correlated with lower baseline heart rates, lower activity heart rates (e.g., during stair climbing), and faster recovery heart rates, indicating better cardiovascular health. ⁹

Physical Fitness

Playful activities can enhance physical fitness. Saywell and colleagues, in a systematic review of RCTs, play-based interventions in adults with acquired brain injuries were more effective in improving balance and independence compared to traditional therapy. ¹⁰ They concluded that this “may be due to them being more enjoyable than traditional therapy.”

Stress Reduction

Engaging in playful activities can reduce stress and improve mood. Play has been linked to positive affect and reductions in daily stress, which we work to address in LM owing to the downstream effects of high levels of stress. ¹¹

Social and Psychological Benefits

Play fosters social connections and cooperation, which can indirectly benefit physiological health by reducing stress and promoting a sense of well-being. For instance, group play through exergames (e.g., video games that involve exercise) has been shown to increase social integration and self-efficacy in older adults with serious mental illness, contributing to healthier aging. ¹²

Play’s importance is heightened in our crisis of loneliness, worsened by the pandemic.

A 2021 study revealed that young adults, those with lower incomes and those from racialized minority groups were more likely to be lonely, with 60%–80% in each group meeting criteria for loneliness. ¹³ The U.S. Surgeon General paid particular attention to this issue, insisting we need to “make the same investments in addressing social connection that we have made in addressing tobacco use, obesity, and the addiction crisis. ¹⁴ ” Play serves as a natural way to connect people and to address loneliness.

Integrating Play into Our Lifestyle Medicine Practice

Below are a few ideas that will help you incorporate play into your LM practice.

(1) Start to assess play in your patients, helping them to self-assess play in their lives. We suggest developing a question or two for each of the LM domains related to play, with each clinician guiding what feels best for them and their patients. We have examples of questions for each LM pillar in Supplemental Appendix A.

(2) Knowing your patient, you might find one concrete health issue that you feel play might address and discuss this with your patient. “If you were to play more, how do you think that might affect your insomnia?” Again, the goal is to have patients gain insight and ultimately to self-prescribe the specifics of play that are most appealing to them. We have examples of how to incorporate play into prescriptions for each LM pillar in Supplemental Appendix B.

(3) Incorporate play into individual and group clinic visits. There are lots of ways to go with this, but you might try a playful approach in your visits, taking the same subject matter (e.g., controlling one’s chronic diseases) and reframing it as play. “If your diabetes could talk to you right now, what would it say?” Such an approach, where we are now “playing” with chronic disease may help us avoid putting patients on the defense, opening up the dialogue into new directions.

You might also try playful approaches to open a clinical encounter. For example, “If they were to make a movie about your life over the last 3 months, what would the movie be called?” This question will elicit useful information, but it also conveys a playfulness from the clinician that may help put the patient at ease, inviting them to play along.

Playing More in Our Own Lives

One unique thing about play that we have not mentioned above: clinicians that are actively playing in their lives are going to be most able and most effective at bringing it into their LM practices. So, we will end with a few ideas for how you might assess and amplify play in your life. (Note: these will also increase your toolbox for the above, incorporating play into your LM practice).

(1) As we do in medicine, an initial assessment is a great starting place. You might play with questions such as:

What is my relationship with play at the moment?

Do I have a group of playmates?

What are new ways of playing that I would like to try?

Are there parts of my health/wellness that would benefit from playing more?

(2) Subsequent to #1, try this exercise. Write down the top health/wellness issues you are facing. Now, looking at that list, using some playfulness in doing so, for each issue dream about how/if play could help to address this issue. And for the ones you have a “yes” answer for, think further about what kind of play you might self-prescribe.

(3) Seek out new ways to play and/or new playmates in these months ahead. Thinking of the above definitions of playfulness, there is an element of uncertainty inherent in this, but you might focus on other elements (curiosity, spontaneity, pleasure) as you seek new avenues.

(4) Learn from children in your life. Kids are the best teachers of play. Let the children in your life (patients, family, neighbors) invite you into their world of play, trying not to “parent” or “doctor” but instead to take their lead about how play is going to go.

Supplemental Material

Supplemental Material - Making Room for Play in Lifestyle Medicine

Supplemental Material for Making Room for Play in Lifestyle Medicine by Anthony Fleg and Frederick Miller in American Journal of Lifestyle Medicine

Supplemental Material

Supplemental Material - Making Room for Play in Lifestyle Medicine

Supplemental Material for Making Room for Play in Lifestyle Medicine by Anthony Fleg and Frederick Miller in American Journal of Lifestyle Medicine