Resistance training

1. Introduction

Version followed: resistance exercise training (RET) as studied in the randomised-trial meta-analyses of Gordon and colleagues on depressive symptoms (JAMA Psychiatry, 2018) and anxiety (Sports Medicine, 2017), used here as a behavioural intervention that the psychotherapist assesses, plans and monitors while a qualified exercise professional designs and supervises the training itself. Safety screening follows the American College of Sports Medicine (ACSM) preparticipation screening model (Riebe et al., 2015) and the WHO 2020 guidelines on physical activity. No published psychotherapist treatment manual for RET is known [uncertain: not verified]; the session structure below is therefore [synthesis] built on those sources.

What it is. Resistance training means exercise in which muscles work against a resistance (body weight, bands, free weights or machines) to build strength and muscular endurance. In the psychotherapy context it is not a therapy school but an activity the client takes up between sessions, with the therapist supporting the decision, the start, the habit and the meaning it carries. [source: Gordon et al., 2018; Gordon et al., 2017]

What the evidence says, as attributed facts.

Gordon et al. (2018) pooled 33 randomised trials (1,877 participants) and reported that RET was associated with a moderate reduction in depressive symptoms compared with non-active controls; the effect did not depend on health status, total prescribed volume or whether strength improved, and trials with blinded allocation or assessment showed smaller effects. The authors called for better-blinded trials and comparison with established treatments. [source: Gordon et al., 2018, Iowa State repository record]
Gordon et al. (2017) pooled 16 articles (922 participants) and reported a smaller but significant reduction in anxiety symptoms; the effect was larger in healthy participants than in those with a physical or mental illness, and was not moderated by programme length, session features or strength gains. [source: Gordon et al., 2017, University of Limerick record]
The WHO 2020 guidelines recommend muscle-strengthening activities for all age groups (for adults, on two or more days a week at moderate or greater intensity, as a public-health recommendation), state that "some physical activity is better than none", and advise starting small and building gradually. [source: Bull et al., 2020, BJSM]
NICE's 2022 decision aid on first-line treatments for less severe depression lists group exercise among eleven options, sixth in its order of recommended use. Whether resistance exercise specifically fits NICE's group exercise format, and the format details, are [uncertain: not verified]. [source: NICE, 2022]

Core idea of how change happens. The meta-analyses found benefits that did not track strength gains, so change is unlikely to be only about physical fitness [source: Gordon et al., 2018; 2017]. Clinically, likely routes include mastery and self-efficacy, behavioural activation (scheduled, valued, rewarding activity), a changed relationship with the body, structure and routine, and social contact in supervised or group settings [synthesis; mechanisms not established in the cited sources]. The therapist's job is to make those routes available safely, and to spot the minority for whom lifting feeds a problem (muscle dysmorphia, compulsive exercise, eating disorders, anabolic steroid use) rather than helping.

Who does what. The psychotherapist assesses, screens, plans collaboratively, refers, monitors mental-health outcomes and adverse psychological effects, and works with the meaning of the activity. The exercise professional (and, where needed, the client's physician) decides on exercise selection, technique, load, sets, repetitions, progression and physical safety. This guide gives no exercise prescriptions. [synthesis; referral standard from Exercise is Medicine Health Care Providers' Action Guide]

2. Framework

The stages below are [synthesis], organised around the sources' safety and referral steps. They typically run within ongoing psychotherapy rather than as a separate course: assessment and planning usually take parts of one to three sessions, followed by brief check-ins in most later sessions and periodic fuller reviews. Format: individual sessions; can be adapted to groups.

Stage 1. Assessment and screening. Goal: understand the client's activity history, relationship with exercise and body, readiness, and safety. Includes physical-safety screening (ACSM's three factors: current activity level; signs or symptoms, or known cardiovascular, metabolic or renal disease; desired intensity) and psychological screening for eating disorders, compulsive exercise, muscle dysmorphia and performance-enhancing drug use. [source: Riebe et al., 2015; Pope et al., 2014; Meyer et al., 2016] Move on when: screening is done; any red flag has a plan (medical review, specialist eating-disorder assessment, or a decision not to pursue RET now); the client is at least considering the idea.

Stage 2. Psychoeducation and collaborative planning. Goal: an honest shared picture of what RET might offer, matched to the client's values, and a first plan for format and setting (supervised one-to-one, small group, community class, home-based with professional guidance). Readiness is matched to stage of change as in the Exercise is Medicine guide: information and encouragement for earlier stages, a plan and referral for later stages. [source: Exercise is Medicine Action Guide] Move on when: the client chooses to try it and has named a first concrete step.

Stage 3. Clearance and referral. Goal: medical clearance where ACSM screening indicates it, and linkage with a qualified exercise professional. [source: Riebe et al., 2015; Exercise is Medicine Action Guide] Move on when: clearance is obtained or not required, and the client has a booked first contact with a professional or programme.

Stage 4. Starting and early support. Goal: get through the first weeks, when drop-out is common [synthesis]. Barrier problem-solving, implementation planning, behavioural-activation linkage, and processing first experiences (fear, shame, pride, pain). Move on when: the client has attended or practised on several occasions and can describe what helps and what gets in the way.

Stage 5. Monitoring and review. Goal: track mood, anxiety, functioning, enjoyment and adverse effects; keep the activity serving the treatment goals; coordinate with the exercise professional. Repeat the psychological screen if body-image, eating or exercise-rigidity signs appear. [synthesis] Move on when: engagement is stable and the client can self-monitor.

Stage 6. Maintenance and relapse prevention. Goal: a sustainable habit that survives disruptions (illness, injury, travel, low mood), and a plan for what to do when it lapses. [synthesis] End when therapy ends, with the plan written down.

At any stage, return to Stage 1 if new physical symptoms, injury, pregnancy, a new diagnosis, eating-disorder signs, compulsive patterns or steroid use emerge. WHO advises that people who develop new symptoms when increasing activity should consult a healthcare provider. [source: Bull et al., 2020]

3. Guiding principles

Psychotherapist stays in role. Practical meaning: you support the decision and the habit; you do not choose exercises, loads, sets, repetitions or progressions, and you do not demonstrate or correct technique. Codes require practising within competence, e.g. UKCP item 23 ("Offer only the forms of therapy in which you have had adequate training") and APA Standard 2.01. [source: UKCP Code 2019; APA Ethics Code]
Safety first, without needless barriers. Practical meaning: screen with the ACSM model and refer for clearance when it indicates, but do not demand medical clearance for everyone; ACSM revised its model because over-referral discouraged exercise. [source: Riebe et al., 2015; ACE article on the new guidelines]
Honest framing of evidence. Practical meaning: present RET as associated with reduced depressive and anxiety symptoms in trials, with uncertainty about trial quality, and as an addition to, not a replacement for, recommended treatment. [source: Gordon et al., 2018; 2017]
Benefit does not depend on getting stronger. Practical meaning: shift goals away from numbers lifted or appearance and towards doing it, enjoyment, mastery and mood; this also lowers the risk of feeding body-image problems. [source: Gordon et al., 2018; 2017 (strength gains did not moderate effects); framing is synthesis]
Some is better than none. Practical meaning: a small, achievable start is a success; avoid all-or-nothing plans. [source: Bull et al., 2020]
Collaboration and choice. Practical meaning: the client decides whether, where, how and with whom; you offer options, not instructions. [synthesis; readiness-matching from Exercise is Medicine Action Guide]
Screen for the downside. Practical meaning: ask every client considering or already doing resistance training about eating, body image, rigid or driven exercise and performance-enhancing drugs, and repeat if signs appear. [source: Pope et al., 2014; Meyer et al., 2016; Çınaroğlu & Yılmazer, 2025]
Referral to qualified professionals. Practical meaning: check degree, accredited certification, CPR/AED, insurance and experience with the client's population before recommending a trainer or programme. [source: Exercise is Medicine Action Guide]
Consent and the body. Practical meaning: prepare clients, especially those with trauma histories, for hands-on cueing or spotting by trainers; they may ask for verbal cues only and stop any touch at any time. Never sexual touch. [synthesis; consent and right-to-refuse wording parallels the USABP Code, Section VIII]
Medical team and medication stay with the medical team. Practical meaning: never advise starting, stopping or changing medication or medical care; pass new physical symptoms to the physician. [synthesis]
Integrate, don't bolt on. Practical meaning: link the activity to the formulation (behavioural activation, avoidance, self-criticism, body relationship) and bring the client's experiences of training back into the session. [synthesis]

4. Intervention inventory

The sixteen interventions below are the psychotherapist's tasks. Except where a source is named, the step-by-step procedures are [synthesis]: the cited sources supply the evidence, safety model, screening instruments and referral standards, not session scripts. All example language is illustrative.

4.1 Activity and relationship-with-exercise history

Purpose / when: Stage 1, for any client for whom RET is being considered, and for clients who already lift. Builds the formulation and spots risks.
Steps: (1) Ask what physical activity the client does now and has done before, including any past resistance training, sport or gym use. (2) Ask what exercise has meant: enjoyment, punishment, compensation for eating, appearance, competition, escape, belonging. (3) Ask about experiences of PE, sport or gyms (shame, bullying, injury, being watched, touch by coaches). (4) Ask what gets in the way now (energy, pain, cost, childcare, social anxiety, shift work). (5) Note current level, because ACSM screening depends partly on whether the person already exercises regularly. [source for step 5: Riebe et al., 2015] (6) Summarise back and link to the formulation.
Example language (illustrative): "Before we think about whether strength training could help, I'd like to understand your history with exercise: the good parts and the parts that felt bad." / "When you've exercised in the past, what was it for, in your own words?"
Watch for: exercise described as compensation, rules or guilt; distress when unable to train; appearance as the only motive; history of injury or medical conditions to pass to screening. Working: the client can name personal reasons and barriers, and you have enough to plan.

4.2 Physical-safety and medical-clearance screening

Purpose / when: Stage 1 and whenever health changes. Decide whether medical review is needed before starting or increasing exercise.
Steps: (1) Explain why you are asking. (2) Ask about the three ACSM factors: whether the client currently exercises regularly; known cardiovascular, metabolic or renal disease; and signs or symptoms suggestive of such disease (for example chest discomfort, breathlessness out of proportion, fainting, palpitations, ankle swelling, as commonly listed [uncertain: not verified as the full ACSM symptom list]); and the intensity the client intends. [source: Riebe et al., 2015] (3) Ask also about pregnancy, recent surgery, injuries, joint or back problems, uncontrolled blood pressure, and medications that the physician should consider [synthesis]. (4) Where any of these apply, or you are unsure, ask the client to see their physician before starting, and with consent write a short note saying what is planned in general terms. (5) Where nothing applies, note that, and tell the client the exercise professional will do their own screening (many use a standard readiness questionnaire such as the PAR-Q+ [uncertain: not verified]). (6) Tell every client: new symptoms during or after exercise mean stopping and seeking medical advice. [source: Bull et al., 2020]
Example language (illustrative): "I'm not the person who decides what exercise is safe for your body, but I can check a few things that tell us whether your doctor should see you first." / "If you ever get chest pain, feel faint or very breathless while training, stop and get it checked, the same day if it's severe."
Watch for: clients minimising symptoms to avoid a doctor's visit; health anxiety that turns screening into reassurance-seeking (keep it brief and factual); clients with eating disorders, who may be medically unstable even when they look well (route to their medical team) [synthesis]. Working: a clear documented decision (clearance needed or not) and the client knows the stop-and-seek-help rule.

4.3 Eating-disorder and compulsive-exercise screening

Purpose / when: Stage 1 for everyone considering RET; repeat in Stage 5 if signs appear. Compulsive exercise is described as a rigid, highly driven urge to be active, where the person feels unable to stop even when aware of harm. [source: Meyer et al., 2016]
Steps: (1) Use the eating-disorder screener your service already uses, or a clinical interview, about restriction, binge eating, purging, weight and shape concerns [synthesis]. (2) Ask about exercise rules, guilt or anxiety when a session is missed, exercising through injury or illness, and exercise used to control weight or to "earn" food. (3) Where concern exists, a standardised measure can help: the Compulsive Exercise Test (Taranis, Touyz & Meyer, 2011), a 24-item self-report with five subscales (avoidance and rule-driven behaviour; weight-control exercise; mood improvement; lack of exercise enjoyment; exercise rigidity). Meyer et al. (2016) found it acceptable in adult women with eating disorders and reported a cut-off with acceptable accuracy, while advising caution with the mood-improvement subscale and noting it has not been validated against clinical interview. [source: Meyer et al., 2016] Obtain the instrument from its authors or publisher; do not improvise items. (4) If an eating disorder or compulsive exercise is likely, do not start RET as an intervention; refer for specialist eating-disorder assessment and coordinate any activity decisions with that team. [synthesis]
Example language (illustrative): "Some people find exercise lifts their mood; for others it starts to feel like a rule they can't break. Has it ever felt like that for you?" / "What happens inside you if you have to miss a session?"
Watch for: guilt, panic or compensation when sessions are missed; exercise rising as food intake falls; secrecy; injury ignored. Working: risk is either ruled out with reasonable confidence or routed to specialist care.

4.4 Muscle dysmorphia and performance-enhancing drug screening

Purpose / when: Stage 1 for anyone already lifting or wanting to "get bigger", and especially young men and regular gym users; repeat if signs appear.
Background (attributed): A systematic review of muscle dysmorphia (MD) assessment describes people with MD as preoccupied with their body size, lifting weights on most days of the week, following high-protein diets, and sometimes using supplements and steroids; the reviewed studies used diagnostic criteria proposed by Pope et al. (1997). [source: Lopez-Cuautle et al., 2016] DSM-5 places MD as a specifier of body dysmorphic disorder [uncertain: not verified]. A 2025 meta-analysis reported that anabolic steroid users had significantly higher MD symptoms than non-users and that MD symptoms correlated moderately with obsessive-compulsive traits; qualitative studies described compulsive training routines and limited engagement with healthcare. [source: Çınaroğlu & Yılmazer, 2025] The Endocrine Society states that most users of performance-enhancing drugs are non-athlete weightlifters, often at doses far above physiological levels and combined with other drugs, and links use to increased risk of death and to cardiovascular, psychiatric, endocrine, hepatic, renal, infectious and other disorders; it also names an anabolic-steroid withdrawal syndrome. [source: Pope et al., 2014]
Steps: (1) Ask about body image in neutral terms (size, muscularity, leanness, checking, comparing, avoiding being seen). (2) Ask about impact: time spent on training and diet, missing work or social life, training through injury, distress when unable to train. (3) Ask directly and non-judgementally about supplements, anabolic steroids and other performance or image-enhancing drugs, current and past, including injecting. (4) If MD is likely, assess as for body dysmorphic disorder using your service's standard instruments [synthesis]; validated MD measures exist in the research literature but which to prefer is [uncertain: not verified]. (5) If steroid use is disclosed, see 4.15.
Example language (illustrative): "Lots of people who train use supplements, and some use steroids or other drugs. I ask everyone, not to judge, but because it affects mood and health and I'd rather know." / "How much of your day goes on thinking about your size or your training?"
Watch for: feeling small despite visible muscularity; mirror checking or avoidance; rigid diet and training rules; mood swings, irritability or low mood after stopping a cycle (possible withdrawal); secrecy. Working: the client speaks openly about body image and substance use, and a plan exists.

4.5 Evidence-informed psychoeducation

Purpose / when: Stage 2. Gives an honest rationale that supports informed choice.
Steps: (1) Say in plain words what trials found: on average, people doing RET had fewer depressive symptoms and, to a smaller degree, fewer anxiety symptoms than people in non-active control groups. [source: Gordon et al., 2018; 2017] (2) Say what is uncertain: better-blinded trials found smaller effects, and RET has not been well compared with established treatments. [source: Gordon et al., 2018] (3) Say that benefits did not depend on how much strength people gained. [source: Gordon et al., 2018; 2017] (4) Present it as an addition to the current plan. (5) Ask what the client makes of it.
Example language (illustrative): "Studies suggest strength training can ease low mood for many people. It's not a cure and it doesn't replace what we're doing; and interestingly, the benefit didn't seem to depend on getting stronger."
Watch for: overselling (sets up failure and self-blame); clients hearing it as "you're depressed because you don't exercise". Working: the client can restate the rationale in their own words with realistic expectations.

4.6 Readiness and motivational conversation

Purpose / when: Stage 2 and whenever ambivalence appears. Matches the plan to readiness; Exercise is Medicine sorts readiness into five stages of change, with information and encouragement earlier and a plan and referral later. [source: Exercise is Medicine Action Guide]
Steps: (1) Ask how ready the client feels, perhaps on a 0–10 scale [synthesis]. (2) Explore reasons for and against in the client's words. (3) Reflect change talk; do not argue against the reasons not to. (4) If not ready, offer information and leave the door open. (5) If ready, move to 4.7.
Example language (illustrative): "Part of you sees it might help, and part of you dreads walking into a gym. Both make sense. What would need to be different for it to feel possible?"
Watch for: compliance to please you ("yes" without energy); therapist pressure. Working: the client voices their own reasons.

4.7 Collaborative planning of format, setting and goals

Purpose / when: Stage 2. Turns intention into a plan the client owns, without prescribing exercise.
Steps: (1) Link to values (strength for daily life, independence, routine, social contact, feeling capable). (2) Set process goals (turning up, trying a class, booking an induction) rather than appearance, weight or load goals. [synthesis, consistent with Gordon et al. finding that benefit did not track strength] (3) Choose format: supervised one-to-one, small-group class, community or rehabilitation programme, or home-based training with professional guidance; consider social anxiety, cost, access, cultural or gender preferences (e.g. women-only sessions), and trauma triggers such as mirrors or being watched. (4) Note WHO's public-health recommendation exists and that some activity is better than none, so the first step can be small; leave frequency and content to the exercise professional. [source: Bull et al., 2020] (5) Agree the first concrete step and write it down.
Example language (illustrative): "Rather than a target for how much you lift, what would 'this went well' look like at the end of the month?" / "Which setting feels least daunting: a trainer one-to-one, a small class, or starting at home with guidance?"
Watch for: appearance or weight goals creeping in (revisit 4.3 and 4.4); over-ambitious plans driven by perfectionism. Working: a written first step the client chose.

4.8 Referral to a qualified exercise professional

Purpose / when: Stage 3. RET design, supervision and progression belong to a qualified professional.
Steps: (1) Explain the referral and who does what. (2) Help the client check credentials. Exercise is Medicine advises looking for a relevant four-year degree, an accredited (it recommends NCCA-accredited) fitness or clinical certification, CPR/AED certification, liability insurance and experience with the relevant population; it names certifying bodies including ACSM, ACE, the Cooper Clinic, NSCA and NASM, and an EIM credential. [source: Exercise is Medicine Action Guide] Outside the US, use the equivalent national register or accredited clinical exercise physiologist or physiotherapist route [synthesis]. (3) For clients with significant medical or mental-health complexity, prefer clinical-level professionals (clinical exercise physiologists, physiotherapists, or programmes in health services) [synthesis]. (4) With written consent, share only what the professional needs: that the client is in psychological therapy, relevant safety points, preferences (e.g. verbal cues only), and how to contact you. Do not share diagnoses beyond what the client agrees. (5) Agree how you will hear back.
Example language (illustrative): "I'll help with the mental side; the trainer decides what exercises and how much. Shall we look together at what to ask them about their qualifications?" / "What would you like the trainer to know about you, and what would you rather keep between us?"
Watch for: trainers who offer diet plans, supplements or drugs, or who promote extreme or appearance-driven programmes (redirect); clients choosing unqualified providers because of cost (help find low-cost community or health-service options). Working: first appointment booked with a credentialed professional; consent for liaison in place.

4.9 Preparing for touch, being seen and gym environments

Purpose / when: Stage 3–4, especially for clients with trauma histories, social anxiety or body shame. Trainers may use hands-on cueing or spotting, and gyms involve mirrors, being watched and close physical proximity.
Steps: (1) Ask what the client expects and fears about the setting. (2) Explain that they can ask the trainer for verbal or demonstrated cues only, can agree touch item by item, and can stop any touch at any time. (3) Rehearse a short phrase for setting the boundary. (4) Plan grounding strategies the client already knows for moments of distress. (5) Agree what the client will do if anything feels unsafe (stop, leave, tell you, use the facility's complaint route). The psychotherapist does not provide hands-on correction; any sexual touch by anyone is never acceptable and is a safeguarding and complaints matter. [synthesis; consent and right-to-refuse principles parallel the USABP Code, Section VIII; codes such as UKCP, BACP and APA prohibit sexual contact with clients]
Example language (illustrative): "You're allowed to say 'I'd prefer you show me rather than touch me.' Shall we practise saying that out loud?"
Watch for: freezing or dissociation when describing touch or being watched; a plan to "just push through". Working: the client has a boundary phrase and a plan, and reports using it.

4.10 Barrier problem-solving and implementation planning

Purpose / when: Stage 4, and any time attendance drops.
Steps: (1) List likely barriers (energy, mornings, cost, transport, childcare, self-consciousness, pain). (2) For each, generate options together and pick one. (3) Form if-then plans tied to cues ("If it's Tuesday after work, then I go straight from the office"). (4) Plan for low-mood days with a smaller fallback the trainer has approved. (5) Review next session.
Example language (illustrative): "What's most likely to stop you this week? Let's decide now what you'll do if that happens."
Watch for: plans that depend on feeling motivated first; the therapist doing the problem-solving. Working: the client anticipates obstacles and uses fallbacks rather than abandoning the plan. [synthesis]

4.11 Linking RET to behavioural activation and the formulation

Purpose / when: Stage 4–5, for depressed or withdrawn clients and those using avoidance.
Steps: (1) Schedule sessions as valued activities in the client's activity plan. (2) Before and after, ask the client to note mood and sense of achievement on a simple scale. (3) Review in session: what changed, what thoughts showed up ("everyone's looking at me", "I'm useless"), what they did anyway. (4) Link to the formulation: avoidance loop, self-criticism, low mastery. (5) Generalise: what else could be approached the same way.
Example language (illustrative): "Your rating went from 3 before to 5 after. What do you make of that, given that you nearly didn't go?"
Watch for: RET becoming the only activity tracked; ratings used to judge performance; mood not improving at all (review fit, depression severity, medical factors). Working: the client notices mood shifts after activity and uses this to act against low mood. [synthesis]

4.12 Self-monitoring of mood, engagement and wellbeing

Purpose / when: Stages 4–6. Keeps focus on mental-health outcomes rather than performance.
Steps: (1) Agree what to track: attendance or practice, enjoyment, mood or anxiety before and after, sleep, pain or injury, and urges or guilt around exercise. (2) Leave loads, sets and repetitions to the client's trainer; do not use them as therapy outcomes. (3) Use your usual standardised depression or anxiety measures at agreed intervals. (4) Review trends together.
Example language (illustrative): "Let's keep a note of how you feel and whether you enjoyed it, not how much you lifted. The trainer can track the numbers."
Watch for: obsessive logging, weighing or body measuring; distress at missed entries (signals for 4.3 and 4.4). Working: the log is brief, used, and informs decisions. [synthesis]

4.13 Processing the bodily and emotional experience in session

Purpose / when: Stages 4–6. Uses training experiences as therapeutic material.
Steps: (1) Invite a specific recent session. (2) Explore sensations, emotions and thoughts before, during and after (effort, fatigue, strength, shame, pride, anger). (3) Notice themes: mastery, permission to take up space, tolerating discomfort, self-compassion after a bad session. (4) Connect to life outside the gym. (5) Notice and name any shift towards appearance-focus or punishment.
Example language (illustrative): "When you finished that last set and felt your legs shaking, what went through your mind?" / "You said you felt 'solid'. Where else would you like to feel like that?"
Watch for: physical distress being reinterpreted as weakness or failure; trauma memories activated by effort, breathlessness or confined positions (slow down, ground, and talk with the trainer about alternatives). Working: the client describes the body with more neutrality or warmth and links experiences to goals. [synthesis]

4.14 Review, monitoring and coordination with the exercise professional and medical team

Purpose / when: Stage 5 at regular intervals, and immediately after any adverse event.
Steps: (1) At set points, review symptom measures, functioning, engagement and enjoyment. (2) Ask about pain, injury, new physical symptoms and medical changes; pass new symptoms to the physician. [source: Bull et al., 2020] (3) Re-screen for eating, body-image, compulsive-exercise and drug-use signs. (4) With consent, liaise with the trainer about attendance, observed distress or safety concerns; stay out of programme design. (5) Decide jointly to continue, adapt the format, pause or stop.
Example language (illustrative): "It's been some weeks. Let's look at whether this is helping your mood, and whether anything about it worries you."
Watch for: benefit not appearing despite good engagement (consider other treatments; RET is an addition); adverse psychological effects such as rising rigidity, irritability, sleep loss or mood swings. Working: a documented decision based on outcomes. [synthesis]

4.15 Responding to disclosure of anabolic steroid or other performance-enhancing drug use

Purpose / when: Whenever use is disclosed or suspected.
Steps: (1) Thank the client and stay non-judgemental. (2) Ask what, how (including injecting and sharing equipment), how long, and why; screen for mood changes, aggression, suicidal thoughts, especially around stopping, since the Endocrine Society names an anabolic-steroid withdrawal syndrome and links use to psychiatric disorders. [source: Pope et al., 2014] (3) Encourage medical assessment and, where available, specialist harm-reduction services (e.g. needle and syringe programmes) [synthesis]. (4) Never advise how to use, cycle or stop drugs; stopping should be medically supported [synthesis]. (5) Explore motives (body image, MD, identity, competition) and work on them therapeutically; the 2025 meta-analysis supports integrated work addressing both body-image and substance dimensions. [source: Çınaroğlu & Yılmazer, 2025] (6) Follow your usual risk-assessment procedure if suicidal thoughts or aggression are present.
Example language (illustrative): "Thanks for telling me. I'm not here to lecture you. I'd like to understand what it does for you, and make sure you're getting your health checked."
Watch for: low mood or suicidal thinking after a cycle ends; aggression or risk to others; injection-related infection signs (medical referral). Working: the client accepts medical review and keeps talking openly.

4.16 Maintenance and relapse-prevention planning

Purpose / when: Stage 6, before therapy ends, or after a lapse.
Steps: (1) Review what helped and what got in the way. (2) Identify high-risk times (illness, injury, holidays, depressive relapse). (3) Write a restart plan with a small first step and who to contact (trainer, physician). (4) Note early warning signs that training is becoming rigid or driven. (5) Agree how RET fits within the wider relapse-prevention plan.
Example language (illustrative): "When you've stopped before, it's been all-or-nothing. What's the smallest way back in that you'd actually do?"
Watch for: perfectionism framing a lapse as failure; dropping all other coping strategies in favour of training. Working: the client has a written, realistic restart plan. [synthesis]

5. Handling problems

The cited sources do not address in-therapy problems; all responses below are [synthesis] unless a source is named.

Stuck or ambivalent client. Return to 4.6; reduce the step (an induction visit, one class, a home session with guidance); explore what the activity represents (past humiliation, fear of failing, "exercise is for other people"). Accept "not now" and revisit later.
Resistance to the idea itself ("you're telling me to go to the gym"). Acknowledge the risk of sounding dismissive; restate that RET is optional and an addition to therapy; return the choice to the client.
Overwhelm or very low energy in severe depression. Scale down to what is possible; prioritise core treatment; consider whether a supervised clinical programme, where available, fits better than an independent gym start. Check risk as usual.
Non-adherence after a good start. Treat as data, not failure: review barriers (4.10), mood and life events; ask what the client would like to keep, change or drop.
Rupture: client feels pushed, judged about body or fitness, or that you have "become their coach". Name it, own your part, step back from the activity agenda and repair before resuming. Check your own beliefs about bodies, weight and fitness in supervision.
Social anxiety or body shame in gyms. Choose a less exposed format (quiet hours, small or single-gender classes, home with guidance); use the experience as graded exposure within your existing anxiety treatment plan, with the client's consent and without forcing exposure.
Trauma activation (touch, confined positions, breathlessness, being watched, a trainer's commanding style). Pause, ground, and process in session; help the client ask the trainer for alternatives or verbal-only cueing; change trainer or setting if needed (4.9).
Pain, injury or new physical symptoms. Stop-and-seek-advice rule; send to physician or physiotherapist; do not advise on training through pain. WHO advises consulting a healthcare provider when new symptoms appear on increasing activity. [source: Bull et al., 2020]
Escalation into rigidity, compulsion or eating restriction. Raise it directly and early; re-screen (4.3, 4.4); shift goals away from RET; refer for specialist eating-disorder or body-dysmorphic assessment; coordinate any continued activity with that team. [screening basis: Meyer et al., 2016; Lopez-Cuautle et al., 2016]
Steroid or other drug use emerges. Follow 4.15; monitor mood closely around stopping; involve medical care. [source: Pope et al., 2014]
Mania or hypomania. Escalating, driven training can be part of overactivity; review with the psychiatric team rather than encouraging more activity.
Psychosis, cognitive impairment or significant physical disability. Prefer health-service or clinical exercise programmes; WHO notes that adults with disability may need to consult a healthcare or physical-activity and disability specialist. [source: Bull et al., 2020]
Medication and medical conditions. Pass questions about medication effects on exercise, blood pressure, blood sugar or heart rate to the prescriber or physician; never change medical treatment.
Poor or unsafe trainer practice (supplement or drug selling, extreme dieting, shaming, ignoring injury, inappropriate touch). Support the client to leave; for touch or sexual misconduct, treat as a safeguarding matter and help with the facility or certifying body's complaint route.
Cost and access. Look for community, health-service or low-cost group programmes, or home-based options with professional guidance.
Children and adolescents. Involve parents or carers, obtain consent and assent, follow safeguarding procedures, use youth-qualified exercise professionals, and screen with particular care for body-image and eating concerns. [synthesis; WHO 2020 includes muscle-strengthening recommendations for children and adolescents, details [uncertain: not verified]]
Therapist's own enthusiasm. A therapist who lifts may over-identify; keep the client's goals central and take this to supervision.

Sources

Web sources

Works cited, not verified directly

Taranis, L., Touyz, S., & Meyer, C. (2011). Disordered eating and exercise: development and preliminary validation of the Compulsive Exercise Test (CET). European Eating Disorders Review, 19(3), 256–268. [uncertain: cited via Meyer et al., 2016; title not verified]
Pope, H. G., et al. (1997). Muscle dysmorphia criteria, as cited by Lopez-Cuautle et al. (2016). [uncertain: not verified]

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