Issue 3 - July/August/September 2011
Welcome to the third edition of TRANSFORMATIONS. In this issue, we present the second in a three-part series, METAMORPHOSIS, based on the transformative experience in psychotherapy of "Laura."
Dr. Katie Barnes offers her insights into "ExerTherapy," and Dr. Eleanor Moreh writes about the psychological and emotional components of well-being in breast cancer patients post-treatment; this article is based in part on Eleanor's recent doctoral dissertation. Congratulations to Dr. Moreh for having recently completed her doctorate in psychology from The Chicago School. And many thanks, as always, to practice administrator Victoria Dekovich for her fine work in assembling and editing this issue of TRANSFORMATIONS.
Our popular feature TRANSFORMATIVE VOICES offers an inspiring quote from an accomplished artist in the community with insight into the processes of growth and change in her personal and professional life. Finally, please enjoy the work of poet Sharon Olds which we feel exemplifies a wonderful experience of true "warmth" between patient and therapist.
I'm pleased to announce our new office location effective July 1, 2011. I will be located at 450 N. Robertson Boulevard, Los Angeles 90048, at the corner of Robertson and Dorrington in the West Hollywood area. Please feel free to call me at 310-550-4560 to make an appointment or contact me via my website at www.drchrisemerson.com. Katie and Eleanor will also be seeing patients at the new location, and Katie will also maintain office space at our current location, 9300 Wilshire Boulevard, Suite 306, Beverly Hills 90212. Dr. Barnes and Dr. Moreh are also currently accepting new patients, and are often willing to work on a sliding fee scale.
As always, we welcome your thoughts, inquiries, comments, and questions.
Dr. Chris Emerson
Some Current Findings Regarding Breast Cancer Survivors and Well-Being
By Dr. Eleanor Moreh
Breast cancer is a highly prevalent medical problem. Current data indicate that each year in the United States more than 192,000 women are diagnosed with breast cancer (National Cancer Institute, 2009). It is the most frequently diagnosed cancer among women, accounting for nearly 1/3 of cancer cases.
Although 98% of women with localized cancer are expected to survive 5 years or more, survival rates decrease for those with regional and metastatic breast cancer (American Cancer Society, 2009). Despite the relatively high survival rates, breast cancer is the second leading cause of cancer death among women after lung cancer, with 40,170 deaths from breast cancer each year. Breast cancer rates have increased over the past 20 years, but mortality has decreased. This is probably due in part to screening and early detection. Currently there are more than 2,500,000 breast cancer survivors in the United States (American Cancer Society, 2009).
For women with breast cancer, surgery is often followed by chemotherapy, radiation therapy, and hormone therapy for five years from the initial diagnosis. These treatments present additional difficulties for a woman who is already coping with having a life-threatening disease.
Considering the difficulties posted by treatment for breast cancer, it is tempting to presume that completion of such treatment is a welcomed event. However, there is some evidence that patients may be particularly distressed when their treatment for breast cancer ends. Most current health psychology research suggests that women may experience disrupted adjustment during the months following the end of breast cancer treatment, in part due to the loss of a safety net associated with regular treatment, coupled with uncertainty regarding the cancer recurrence.
For my doctoral dissertation, I recently completed a study of seven women diagnosed with breast cancer based on levels of depression and anxiety at the time of diagnosis and post treatment for breast cancer (Moreh, 2011). The purposes of this study were (a) to determine whether women with breast cancer experience psychological distress at the termination of therapy treatment, and (b) to identify factors predicting distress.
The findings of my study indicated that levels of anxiety increased immediately after the end of breast cancer treatment while the relative level of depression decreased. Nonetheless, women acknowledged significant concerns about the ongoing physical symptoms, emotional adjustment, potential recurrence, and the process of returning to or building a new normal life after breast cancer.
Women who (a) perceived greater control over their cancer, (b) saw their cancer as an acute rather than chronic condition, and (c) attributed cancer to controllable causes or believed that behavioral or psychological factors could prevent recurrence were more likely to make behavior changes and engage in positive health practices.
To summarize, breast cancer patients actively attempt to create a new normal life following treatment, and changes in health practices appear to be an important part of this process. Assessing women's beliefs about their breast cancer and providing psychoeducational interventions that address post-treatment behavior and emotional changes may assist in promoting breast cancer survivors' psychological and physical well- being.
By Dr. Katie Barnes
In his 2008 book, Spark: The revolutionary new science of exercise and the brain, John J. Ratey, M.D. makes one compelling argument after another for the ways in which exercise can alleviate and even reverse conditions such as anxiety, depression, ADD, menopause, and the aging brain. In this short-hand version of his remarkable text, I hope to convince you of the same in regards to exercise's effects on learning, anxiety and depression.
How exercise works on the brain:
Scientists know that exercise improves learning on three levels: first, it optimizes your mindset (elevates specific neurotransmitters) to improve alertness, attention, and motivation. Second, it prepares and encourages nerve cells to bind to one another, which is the cellular basis for processing and storing new information. Third, it spurs the development of new nerve cells from stem cells in the hippocampus, the area responsible for learning and memory, also the first area to degenerate in Alzheimer's disease.
Exercise also diminishes anxiety by working on both the body and the brain. It provides distraction from worries or invasive thoughts, it reduces muscle tension that feeds into the body-mind anxiety loop much like prescribed beta-blockers do, and it increases serotonin, which works at nearly every junction of the anxiety circuitry, promoting a calmed sensation, improving the performance of the prefrontal cortex to inhibit fear, and calming the amygdala or "anxious fear" center. By sparking the sympathetic nervous system or the "calming" system, exercise inhibits the amygdala's functioning and makes new pathways with alternative, "healthy" thoughts. Thus, it can create an alternative reality, free of anxious thoughts. Finally, exercise creates a sense of self-mastery, which raises self-esteem, combating both anxiety and depression.
If depression is defined as an absence of movement toward anything, then exercise is the way to divert those negative signals and trick the brain into coming "out of hibernation." MRI imaging studies have shown that the brain's gray matter, white matter and hippocampus are significantly more deteriorated in depressed persons than in those who are not depressed. Those studies have also shown physical regrowth of all three of these areas relative to how much one begins to exercise. If depression is a state in which the brain's neuronal connections are shut down and deteriorated, then reforming these connections through exercise is tremendously effective treatment. Ratey lists three clinical studies supporting this notion. For example, in 1999, a large study done at Yale University found that a group of depressed participants who exercised by walking or jogging for 30 minutes, three times a week, saw an equal drop in symptoms as the group of participants assigned to take Zoloft, and not exercise. Blumenthal concluded that exercise was as effective as medication in treating depression (Blumenthal, 1999).
How much and what type should I do?
Now one might ask how much exercise is ideal, and what type of exercise is effective for building my brain? The definitive answer is that more research needs to be done in order for us to know specific amounts. However, Ratey notes the following: a 2007 experiment showed that cognitive flexibility improves after just one thirty-five minute treadmill session at either 60 or 70 percent of maximum heart rate. Aerobic exercise that significantly elevates the heart rate is what has been shown to elevate the "feel-good" and motivating neurotransmitters. To optimize learnability and brain plasticity, what Ratey suggests is to either choose a sport that simultaneously challenges the cardiovascular system and the brain, such as tennis or volleyball, or do a ten-minute aerobic warm-up before something nonaerobic and skill-based, such as rock climbing or yoga. The more complex the movements, the more complex the synaptic connections that are made.
In tackling depression, one study compared a group of participants exercising at a high-intensity level, 3-5 times per week (burning 8 calories per pound of body weight per week), and a group exercising at a low-intensity (burning 3 calories per pound per week). The high-intensity group lowered their depression scores by half, and the low-intensity group lowered their depression scores by one-third. So, both amounts of exercise were effective, but the effectiveness directly correlated with the amount of energy expended per week. Aerobic exercises such as running are most highly recommended, at least 3 times per week for at least 35 minutes per session, to best alleviate symptoms of anxiety and depression. Finding something that you enjoy and are most likely to stick to is key, so that the effects have the chance to impact your life and keep you feeling and performing well.
For more on this topic, read Spark: The revolutionary new science of exercise and the brain, by John J. Ratey, M.D., with Eric Hagerman (2008).
The Space Heater
by Sharon Olds
On the ten-below-zero-day, it was on,
near the patients' chair, the old heater
kept by the analyst's couch, at the end,
like the infant's headstone that was added near the foot
of my father's grave. And it was hot, with the almost
laughing satire of a fire's heat,
the little coils like hairs in Hell.
And it was making a group of sick noises-
I wanted the doctor to turn it off
but I couldn't seem to ask, so I just
stared, but it did not budge. The doctor
turned his heavy, soft palm
outward, toward me, inviting me to speak, I
said, "If you're cold-are you cold? But if it's on
for me . . ." He held his palm out toward me,
I tried to ask, but I only muttered,
but he said, "Of course," as if I had asked,
and he stood and approached the heater, and then
stood on one foot, and threw himself
toward the wall with one hand, and with the other hand
reached down, behind the couch, to pull
the plug out. I looked away,
I had not known he would have to bend
like that. And I was so moved, that he
would act undignified, to help me,
that I cried, not trying to stop, but as if
the moans made sentences which bore
some human message. If he would cast himself toward the
outlet for me, as if bending with me in my old
shame and horror, then I would rest
on his art-and the heater purred, like a creature
or the familiar of a creature, or the child of a familiar,
the father of a child, the spirit of a father,
the healing of a spirit, the vision of healing,
the heat of vision, the power of the heat,
the pleasure of the power.
Part II of a three-part interview with "Laura"
By Christopher Emerson, Ph.D.
Dr. Chris Emerson recently interviewed a 45-year old woman named "Laura" who agreed to speak in detail about her experience in psychotherapy over the last 25 years. In this second of three installments of Chris's interview with Laura, they speak about how Laura's therapy "opened up" her world, the relief of her depressive symptoms, and the experience of moving from a patient at a training site for therapists to a private practice setting. ("Laura" is a pseudonym of an independent individual who is not and has never been a patient in this practice).
DR. CHRIS EMERSON: Laura, when we left off, you had just started your second round of psychotherapy with a new psychologist at a community-based mental health center. How was that experience for you?
LAURA: Well, as I told you, I was initially a bit apprehensive. I was assigned a therapist without any input from me, but from the time I first met with James - he had just gotten a Ph.D. a couple of months before, I remember him saying - I was comfortable right away. We decided to see each other two times a week right from the get go, and since they accepted sliding scale payments, I was able to manage it even on my very meager salary.
CE: What was different about therapy this time?
L: It just seemed more intense, more at a "core" level. There wasn't any "homework" like the last time, but there sure was a lot more silences, more time and space for my feelings and my thoughts to form and come out into the therapy room. It was odd at first, a little scary. I thought, "Is it OK for me to sit silently with this guy? Am I doing this right?" But very quickly, I came to feel like that time for reflection was a big part of what had been missing for me - in my life, in my relationships... in my relationship with myself, to tell you the truth.
CE: What kind of changes in yourself did you begin to see in this therapy experience?
L: It was strange at first, but James kept putting a lot of emphasis on the relationship between us, between therapist and patient. I didn't really see the point so much... but gradually we began to see patterns between what was coming up in the therapy relationship and patterns in my other relationships.
CE: How so?
L: Well, little things. .. I never thought of myself as an angry person. I was the one who accommodated the needs of others, always went out of my way for others and didn't expect much in return. But with my therapist, we took the time to "process" the feelings I would have when, for example, he needed to cancel or change our appointment times. One summer he had to go away for a couple of weeks to complete some training, and it left me feeling in a way I hadn't felt before... like I had been left behind somehow, and sad. And then angry.
CE: And those feelings of being sad and angry felt new to you somehow?
L: Well, yes and no. It was new to feel them and to also feel free enough to express them with James without the fear that he'd judge me or really abandon me and our work together. But in another weird way, they didn't feel new at all. They were the ways that I had been feeling deep down inside, for a long time... in my family, with relationships with boyfriends that always disappointed me. And with myself, too; this took me a long time to figure out... that I had been so use to being the one to please and take care of other people that I wasn't even aware half the time of my own feelings of disappointment, sadness, anger. It wasn't safe or acceptable to be angry in my own house growing up. My dad's moods and feelings were the only ones that counted. There really wasn't room for me or even for mom or my sister to have strong emotional reactions and responses of our own.
CE: Were these new understandings helpful to you in terms of seeing positive changes in your outlook, in your mood, in how effective you felt in your day-to-day life.
L: Not at first, to tell you the truth. In fact, there was a time when I felt even a bit worse that before, but I don't remember that period lasting very long. It was like, "OK, this is not just a deal where I'm the problem. There's a real family component to the way I've been feeling for years and years. And my responsibility to myself is to recognize the situation and to make the best of what I can't change, and to be really active in changing the parts that I can."
CE: How long did this process of realization take?
L: It's hard to say. I would ebb and flow. Some weeks the depression would feel strong -- stronger than me. And then gradually I began to feel a sense of, I don't know... power. And clarity. Medication helped too.
CE: How did the medication come into play?
L: Well, the clinic where I saw James offered lower cost psychiatric care, so I saw the psychiatrist there for, I don't know, around $75, and he put me on a low dose of anti-depressant. It took about a month or so before I felt any effect, but then - and it was subtle, almost hard to notice at first - I began to feel more like myself. That sounds weird to say, but it was like the self I was supposed to be came to the forefront in some way. I stopped thinking of myself as predominantly sad, or unhappy and pitiful, because the way I felt from the inside out just became... brighter... in small and sometimes not-so-small ways.
CE: What happened then?
L: At the end of about two summers, James told me he was leaving the center to go into private practice. He asked me if I wanted to go with him. And by then, I had made two job changes, and was working for a small publishing company here in LA. We had gone down to one therapy session a week by then, and I could afford to keep seeing him. So we did. It was great to get out of the basement mental health center and up into a real office!
And what was even greater was that I wasn't the same girl who had come in there a couple of years before... in fact, I wasn't even a "girl" at all. I felt like I had gotten to know the "little girl" parts of me, accepted them, and kind of folded them into a new identity as a self-sufficient woman. I still had sad times, of course, and lots of disappointments about the kind of family I didn't have and was never going to have... but I wasn't paralyzed by those things anymore. That was part of my life, but it didn't run my life like it had for years and years.
In the third and final installment of METAMORPHOSIS in our next issue, Laura talks in about ending therapy, moving into new relationships, and starting a family of her own.
This concludes the second issue of our quarterly newsletter, TRANSFORMATIONS. We hope you have enjoyed reading, and remember to check your inbox in October for the next issue!
Chris, Katie, and Dylan
"I always imagined that by the time I hit 45, I'd have books in the world, so when that magic number came and went, and my manuscripts lay in boxes in the garage, I felt not only that I had failed, but also that I was a failure. This thought created chronic stomach problems, and I thought I was going to die. I resonated deeply with Indian poet, Tagore's, words: "For years I have been stringing and unstringing my instrument while the song I have come to sing remains unsung." I hated the idea of leaving this planet without accomplishing what I'd come here to do. But I wasn't sure what I was supposed to be doing. I thought I'd known. I'd thought I was supposed to write books. But since that dream hadn't materialized, and since I knew I was a bright, capable person, I wondered if I should seek fulfillment elsewhere. I continued scribbling in my journal, but quit writing poems and stories, and addressed my most pressing concern: the pain in my stomach. Instead of taking prescription drugs, I radically changed my diet and became a raw vegan. I then began yoga and meditation practices, found a spiritual community, and earned a degree in Spiritual Psychology. I learned there is no such thing as failure-only opportunities for growth; that our bodies are wise teachers, and symptoms, a call to action, not only on the physical level, but mentally and spiritually as well. I began, for the first time, to think of myself as a divine being having a human experience. Compassion came with this awareness, along with clarity. I knew I loved writing, and what I loved was my path, so I learned how to release judgments, look fear in the eye, and forgive myself for misunderstandings, such as believing I had failed. Releasing that thought, released me. Having the courage to engage in work I love-no matter what-is its own brand of success. What matters is what I think. What matters is faith, in myself and in the Universe, and in the understanding that my work is unfolding in divine right order. Life is not a contest or a race. It is not a proving ground or a school in which I'm being graded. But it is filled with lessons, so I keep showing up, pencil in hand."
--Bella Mahaya Carter, Poet & Author, Secrets of My Sex; Writing Teacher and Creativity Coach