Chapter 05  A Graduate Focus in Health Psychology

Title

Chapter 05 A Graduate Focus in Health Psychology

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Identifier

CohenL_01_20160504_C05

Publication Date

5-4-2016

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Professional Path; The Researcher; Mentoring; On Mentoring; Inspirations to Practice Science/Medicine; Influences from People and Life Experiences; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Professional Path

Transcript

Lorenzo Cohen, PhD:

And then I remembered that as an undergrad at Reed I took a course called health psychology and realized that maybe I could focus there. So I could be in medicine but with what really turned me on, which was the psychological side of things, and psychobiology. I wonder if that could be an undergraduate degree. And at that point, which was -- I started grad school in '90, so it would have been '88, '89, looking around the country, there was really only three programs. One at UCSF, one at University of Miami, and one at Uniformed Services University of the Health Sciences in Bethesda, Maryland, which is of course where I ended up going. The other two were very clinically oriented, meaning that you would get a degree in health psychology but you had to be a clinical psychologist. And I didn't have any interest in being a clinical psychologist and the stereotypical clinical psychology, helping and listening to other people's problems. That wasn't what I wanted to do. I wanted to go into research. So I decided to take another year to be a research assistant in Toronto and to live in Toronto, which was where my parents were. I lived in the basement, the typical kid after college going back home. But I had a full-time job and was a research assistant actually for a developmental psychologist.

T. A. Rosolowski, PhD:

And where was this?

Lorenzo Cohen, PhD:

University of Toronto. For Joan Grusec. And what was really interesting about that experience is she gave me tons of autonomy as a research assistant. I knew absolutely nothing about developmental psychology. But I was so well trained as an undergraduate. Not because I'm necessarily that smart, but because the program was just phenomenal at Reed. They treat you like a graduate student. So I was treated like a graduate student, expected to act like a graduate student, did work at the level of a graduate student. And so when I joined Joan's lab I was really her only research assistant. She had this grant and this project. And I really worked with her as a colleague and helped contribute to it and helped in the design, and developed some measures that didn't end up revealing that much, but we added it to the study, and she included me as a coauthor because she felt I contributed meaningfully.

T. A. Rosolowski, PhD:

What was the project?

Lorenzo Cohen, PhD:

It was actually to look at the development of altruism in children. And her area of focus at that point was to understand the role of household chores in the development of altruism. In particular the question of this study that we did was what is the role of assigned household chores for self or for other for the family. So what do you have to do chores-wise in reference to cleaning your room, making your bed? Or do you also take out the garbage, empty the dishwasher, prepare a meal? And then we had measures of prosocial behaviors, we did formal semi-structured interviews with the kids, with both the parents. All these different questionnaires. This was a new research area for me because as an undergraduate as I described to you I was playing with mice and pigeons. So there was not too many -- it was all very objective data. Now I'm literally in people's homes collecting this data. This is what I developed for the study but it didn't show a difference between groups. Partway through the interview I would break my pencil. And then I would start counting to see did the kid respond, do they say anything. I start fumbling around, do they offer, "Do you want a pencil? Do you want a pencil sharpener? At another point in the interview I drop the papers on the floor. And then I start counting. How long? Do they move? And try to position it in a way that was valid. But of course this was the first human-based research that I got involved with. But learned about questionnaire stuff. And so this was all pre grad school. And so that was a great experience. Being so part of the research study and valued by the mentor. So then off I go to Bethesda, Maryland, which is where Uniformed Services University of the Health Sciences is. And my primary mentor there, Andy Baum, was already relatively well-known as a chronic stress researcher. He was one of the founders of the field of health psychology. The American Psychological Association has a division that's called Division 38 which is Division of Health Psychology. There's an APA journal that's called Health Psychology. And he's died now, he didn't certainly follow the practice of health psychology. Before I met him he had been a chronic smoker, horrible diet, overweight, never exercised, chronically stressed. A very harsh mentor.

T. A. Rosolowski, PhD:

Why do you say that?

Lorenzo Cohen, PhD:

He had a temper. I was never the recipient typically.

T. A. Rosolowski, PhD:

What did you learn from all of that experience with him? His mentoring style.

Lorenzo Cohen, PhD:

So he said -- this is at the time I was graduating. So he was a chronic stress researcher and studied in particular Three Mile Island. The interesting thing about the nuclear disaster at Three Mile Island, he was trained as a social psychologist, is that there was no actual meaningful release of fallout, nuclear material, into the environment, but the people lived still in this neighborhood, and they would see the stacks every day. So this was a naturalistic stressor of the people continuing to live there. And then he would have comparison cohort groups. It was a naturalistic manipulation. Actually during my time and somebody who was a couple years ahead of me, we started focusing on the immune system. So with Three Mile Island he actually collected urine samples and looked at stress hormones and he did objective behavioral measures. There was this very strange but something called the proofreading task. And he was able to document that people who were chronically stressed were less accurate at proofreading. So we would have them read two pages of text and they have to circle all the errors in punctuation and spelling and stuff like that. And chronic stress interferes with that ability, controlling education and everything. So during my time in his lab he started to incorporate immune function. And so Uniformed Services University of the Health Sciences, it's important to note, is a medical school. And so we were in a medical school. But part of the graduate program. And it's a medical school that was founded by Jimmy Carter for educating medical doctors. So up until that time the military would pay for their med students to go to other medical schools. And they of course continue to do that today. But they felt that there needed to be a med school that was specifically training military doctors, because there was things that they needed to learn that were very unique to the theater of war. Very forward-thinking, one of the founders of the school said, "We have to have a medical psychology program to deal with the very real issue of stress. So the graduate faculty of course of this program, most of them actually had no interest in the military. None of them were military-oriented. And they had focus on -- stress and cardiovascular disease was one of the folks. Stress and addiction was one of the other folks. My mentor was stress and psychobiology, and in particular the immune system. So we had an interest not so much at that time in HIV at that time and then shifting into cancer. What Andy said to me at the time that I was graduating was "I didn't teach you anything. You came in here knowing everything that you needed to do to be successful as an academic scientist. Although I was really well trained at Reed and my experience with Joan Grusec in Toronto, he taught me how to write grants. He taught me how to have super high expectations of my graduate students and postdocs. So he required of graduate students that before you could even get to your dissertation you had to be part of other people's research and be the research assistant, but then you ultimately had to run your own study from beginning to end, before you were even allowed to do your dissertation. Most of my graduate students I've had here -- and I haven't had a lot -- for their dissertations they've done their own clinical trial. I'm primarily a clinical trialist, so that's what I do. And postdocs, it's the same thing. So as a postdoc I'll hire you, and you'll work on my things, but you must have your own project that is yours that you do from start to finish.

T. A. Rosolowski, PhD:

It's interesting. So it sounds like he was really a hard taskmaster, but he didn't want to create clones. He wanted people to be intellectually independent.

Lorenzo Cohen, PhD:

Yeah. And he passionately cared about what he did. I'm not sure he instilled in me where I am today, where I really want to only be engaging in research that I know will make a difference and will potentially improve the lives of those who we are here for, and in a more dry way changing the standard of care. He was more of a methodologian, and almost setting up experiments to be able to test theories. So more of a classical social psychologist in that sense. But doing it in a real-world environment and within the medical system.

T. A. Rosolowski, PhD:

Interesting. What about the rest of your experience there, outside of Andy Baum's lab?

Lorenzo Cohen, PhD:

In grad school?

T. A. Rosolowski, PhD:

Yeah, when you were in your PhD program.

Lorenzo Cohen, PhD:

What was very unique about the school, and why it was for sure my best choice of the limited options at the time -- and the field has evolved and there's whole societies now and most psych programs have health psychology as a specialty. Rice has just expanded theirs and hired actually Dave Wetter away from MD Anderson to start their health psych program. So what was remarkable and the most influential for me during grad school was the medical school courses. So as part of the requirements to get your PhD in medical psychology, you had to take the medical school courses. And you could pick and choose some, but some were required. We had to take medical physiology, and we had to take pharmacology. We were allowed to take the courses pass-fail, but we had to pass. So you still had to study for the exams. And why that was important is because if we had to just audit them we wouldn't have crammed like all the medical students were doing to actually learn endocrinology and all the details and neuroanatomy and all the rest of it. So you know from earlier on I was interested in medicine but didn't really want to specialize. So this gave me the best of all worlds. And those courses were the most important. I could crack open a social psych textbook and learn about these awesomely fun experiments, the Milgram experiment and the prison experiment, and all these manipulations you do in the lab with these psych experiments. But the only way I was going to learn human physiology is if I had to take a course and read the textbook and had an exam at the end of that quarter. And so I really learned endocrinology. I took immunology because I had a particular interest in the immune system and stress and all of that. The mind-body connection.

T. A. Rosolowski, PhD:

What was happening to your perspective at this time? This was a little bit of a new experience. What was changing for you at this time?

Lorenzo Cohen, PhD:

It became very clear very quickly, and partly because of Andy's personality. He said to me, "Don't you want to be like me one day? And my knee-jerk response was "That's the last thing I want to do is become like you, having 13 graduate students, and you're the editor of a journal and the head of a society, and all these responsibilities. Flash forward, and I'm doing exactly what Andy was doing, and even bigger, unfortunately. But he loved it. His energy came from what he was doing. The contribution he was making to the field. That of course really seemed appealing, to be getting so much satisfaction from your day job.

T. A. Rosolowski, PhD:

Did you have any sense that this was a great field to be in because it was forming, and you'd have a chance to make a mark? Was that part of your thinking at all?

Lorenzo Cohen, PhD:

Not because I would have a chance to make my mark, but because everything was so new in this field, and creating these connections. So this was back when they were early on trying to disentangle why type A behavior was leading to increased rate of heart attacks, and then really showing that it had to do with anger and hostility. It wasn't just being a driven person. It had to do with this emotional side. We were actually looking at the biology and understanding well, how does anger and hostility get into your blood as the mechanism for increasing heart disease. So I was actually a research assistant on another graduate student's research project, who was working with a different mentor, where he would bring people into the lab and acutely stress them. And we drew the blood and we did assays on it, and we measured platelets. And we actually documented, it was one of the earliest studies documenting this, that acute stress speeds the time at which platelets clot, meaning they clot faster, which of course evolutionarily speaking is great if you're stressed. You don't want to bleed out if you're caught by the animal, and most stress evolutionarily speaking was due to predators. But these people were just sitting in a room being yelled at.

T. A. Rosolowski, PhD:

For day after day.

Lorenzo Cohen, PhD:

Well, this was just acute. You could document it in 15 minutes, your blood is going to clot faster. Which again, most of our stress evolutionarily speaking was acute. But then what happens when that acute stress becomes chronic? Day after day your platelets are clotting and clotting and clotting and clotting and sludging. And then all of a sudden you have a heart attack. So starting to see and learning about cardiology and how the heart works that psychological processes -- because everyone in the group, even though I primarily worked with Andy, the salient variable that everyone was researching was chronic stress, because we were a psych department. We looked at other processes, but chronic stress was the backbone of all of it. Then how does social support buffer it? How does coping buffer it? How does meditation buffer it? Andy wasn't an interventionist. Andy was a very pure methodologian. As students some of us did interventions with him, but most of us focused on documenting the harms of stress. And during that time was actually some early research that came out of the University of Miami that was influential on me, which was both exercise research as well as cognitive-behavioral stress management, back in I think 1990 was their first publication, showing that HIV-positive patients who engaged in cognitive-behavioral stress management for 10 weeks had better immune markers. And this was still in the early days of HIV, and being a fatal disease. And so that really turned me on that you have this immunological disease that was a death sentence and that a psychological intervention that only lasted 10 weeks could modify the immune system, and potentially influence outcomes. They later did document that it actually did influence outcomes. Then literally at the other part of the country at the top, you have Jon Kabat-Zinn who coined the term mindfulness-based stress reduction, taking these Eastern philosophies that I had been exposed to since I was born and bringing them into the medical world with meditation and yoga. That was his early research when I was in graduate school.

T. A. Rosolowski, PhD:

Did cancer come into the picture at all at this point?

Lorenzo Cohen, PhD:

Not as a graduate student. My very close colleague whom I continue to collaborate with today, we went through grad school together, she did a study of caregivers, of parents of kids with cancer. But didn't work with cancer patients at that point. My graduate thesis dissertation was a means to an end. Andy had left. He went to Pittsburgh to head psychooncology at the Pittsburgh Cancer Institute. I was already far enough along that I had the choice. Do I just stay, finish up, do my dissertation, or move to Pittsburgh? And I chose to stay. And I guess the seed was planted then. But my dissertation focus was actually again a means to an end, a manipulation in the laboratory around the acute stress of surgery and whether we can buffer the stress of surgery with information or different coping skills. And it was all an acute lab stressor. But I got embedded in the literature. And we were interested in the immune system of course. Embedded in the literature of stress during invasive medical procedures, and the role of information, predictability, active coping versus passive coping. And I tried to manipulate in the lab. And the lab experiment wasn't that interesting in and of itself. But I had a fabulous background system, was immersed in that literature. And interestingly, I didn't know it at the time but one of the researchers whose research was very important in my background section was the research of Raph Pollock [Raphael Pollock, oral history interview]. And of course you know who Raph Pollock is.

T. A. Rosolowski, PhD:

Yeah, I interviewed him.

Lorenzo Cohen, PhD:

So Raph used to be the head of Surgical Oncology here, but he was fascinated, being a surgeon and doing horrible things to people, in how is this harming people. The surgery. Yes, he's curing sarcoma hopefully, but he's cutting into another human being, what are the negative effects? So he was really interested, as you probably heard, in the immune system and what happens to the immune system. This is a physical stressor. The spiking of heart rate and blood pressure and the release of stress hormones. But there's also the psychology. And Raph wasn't as interested in the psychology. But I read that research that he was doing here, and of course others in the country, looking at the negative effects of surgery. So when I graduated it became clear as what you could call a card-carrying psychoneuroimmunologist in 1994 that I had the choice of HIV or cancer. We have evolved of course to learn that even cardiovascular disease is an inflammatory disease and the immune system is intricately linked, but we actually didn't know that in 1994. It's really horrible to think how old I've become. So I had that choice. I was interested in HIV, but the world of cancer was of course totally unknown to me. But the possibilities seemed endless. And Andy wrote a very influential, to some people important, paper in health psychology. I think it was back in 1985 or '87, right when HIV was starting to enter our society and increasing consciousness of it. It was just an opinion piece in health psychology because he had gotten to know what this disease was, at least what we knew at that time, in whom it was happening, which wasn't just gay men but of course that's where it started, and then of course it started to spread because heterosexual encounters and then blood transfusions, all the rest of it. Wrote this position paper that said that as health psychologists the HIV population is a phenomenal place to go and ask all your different health psychology questions. The mind-body connection, the influence of behavior on outcome. So if you're interested in behavior, how do we get people to use condoms. If you're interested in interventions in coping, how do you do that. If you're interested in end of life, you've got that there. Issues of containing infection and the behavioral side of things. The link between maladaptive behaviors of drinking and smoking while you have an immune disease. You can ask those questions if you're interested in addiction. Any question in health psychology you could apply to the HIV population. And that resonated with me at that time in making this choice. For one, it doesn't matter which one I make, because I can answer any question I want in my career within this chronic life-threatening stressor whether we call it HIV or cancer. I'm not a very -- at least at that point as much as I am today -- introspective kind of person. And there wasn't like this aha, oh, it must be cancer. Cancer actually hadn't really impacted my family that much except for the story I shared about Hilda. My grandfather actually had colon cancer, but he lived until 95. Not sure what killed him but he was 95, so it wasn't the colon cancer in his seventies. So chose cancer, and in my second year of grad school met Alison on a Christmas vacation in Toronto, introduced by my mother. My mother was an art teacher, which was very useful when I was with Joan Grusec doing my research assistantship, because I had an in in a school. So I had access to all these families. It wasn't the most representative families. It was a private school. But anyway Alison volunteered the year, she was an intern at the school, and met my mother. And my mother thought she was great. And so when I came home one Christmas she was like, "Oh, why don't you come meet my son? So it was literally a connection at that meeting. And then we started a long-distance relationship. So when I graduated wanted to see if I could make a go of a career up in Toronto. And applied for an NCIC National Cancer Institute of Canada postdoctoral fellowship, and was awarded it. And the study was to do postsurgical stress management in men with prostate cancer. And so the original design of the study was really done by this individual by the name of Paul Ritvo, who was my mentor up at the University of Toronto at Toronto General Hospital. And what I brought to the table was the psychoneuroimmunology component. He had designed the intervention, and it was in the vein of Jon Kabat-Zinn and the mindfulness stuff, group therapy kinds of stuff. It became very quickly apparent when I landed in Toronto that Paul Ritvo didn't have the right kind of training to mentor me. He was just establishing himself. He was trained as a clinical psychologist. The Toronto General Hospital had a psych department. All the psychologists were psychologists, and they had to do psychotherapy with patients. So they were very psychotherapeutically oriented, not very research-oriented. Didn't understand research design, clinical trials. Some people did, and actually I struck up a phenomenal collaboration with this guy named Joel Katz who was a graduate student of Melzack's from McGill University. Melzack is the one who developed the gate theory of pain, that there's this dual -- super famous guy, published in Science. Anyway Joel was very interested, and I know this may all seem tangential, but it actually brings us literally to the study I'm doing today. Joel is a pain researcher, being one of Melzack's graduate students, and was interested in manipulating the anesthesia setting to see how that would influence pain outcomes. So he was doing this early research when I first got there of comparing spinal epidural to general anesthesia. And he did this initial research actually showing that people who had the spinal had less pain postop. So he was playing around with this acute surgical setting, which of course is what I did my dissertation on, even though I wasn't working in the surgical setting. As a graduate student actually I worked on a study where we looked at PCA morphine at Walter Reed Hospital and compared people who had control of their morphine versus not. I wasn't the lead on that. But that was an influential study I was part of, in the medical setting, working with patients around surgery and all that. So anyway, it became quickly apparent that Paul was definitely out of his league. I was in the wrong place. They didn't have the money to support the immune measures. There was a guy there who was actually an early pioneer in the field of psychoneuroimmunology, an immunologist, Reg Gorczynski. But he really was focused in conventional immunology and was willing to support as needed. But we needed to bring in our own money, and there really wasn't a lot of support. So Paul didn't have the intellectual expertise to help guide me further in my career. And it became quickly clear that I wasn't going to be able to do the study. And there was a bit of friction because Paul was trying to form his own -- there was another postdoc with me too who was extremely smart. And we started, as postdocs should do, and as I encourage my postdocs to do, through my introduction, or they can do it on their own, but they sometimes don't have doors opened without the introduction, start to foster collaborations with other doctors in the institution. So Tom Hack, who was the colleague of mine in the graduate program, we sought upon ourselves to go and start fostering a relationship with the head of breast medical oncology to start doing some research. Tom was particularly interested in communication issues and decision making. And Paul was threatened and freaked out and wanted to control and go through me. And it's just like dude, that's not going to happen, because it's not personal, you don't have the same training that we do. Tom did a fellowship at Harvard and I came from arguably the best health psych program in the country.

T. A. Rosolowski, PhD:

Right, you're ready to zoom along and not help the ego of somebody who's not ready.

Lorenzo Cohen, PhD:

So it became quickly apparent that it was a disaster for both of us. Tom left and I yelled down to Pittsburgh, "Andy, I'll bring my own money, will you take me? And he's like, "I knew you would come back.

T. A. Rosolowski, PhD:

We're just a couple minutes of 3:00.

Lorenzo Cohen, PhD:

Let me just finish that thought. And we can pick up after this thought. So I convinced the National Cancer Institute of Canada to allow me to transfer the grant back. Andy had left DC and was now in Pittsburgh, so he was in this whole new position focusing in cancer. My grant that I'd gotten from NCIC was for postsurgical stress management, but because I was very conscious of not wanting to be viewed as taking anyone else's work, I reformulated it and designed the study to be presurgical stress management for men with prostate cancer. And again now we're back to the dissertation, which was looking at presurgical intervention. So I designed this two-session presurgical stress management intervention, and learned how to collaborate with surgeons, and brought this into the urology department in Pittsburgh, and ran a small randomized clinical trial, and was there for two years. And then we can pick up.

T. A. Rosolowski, PhD:

Sounds great. Well, thanks for your time today.

Lorenzo Cohen, PhD:

Yeah, it was fun, I look forward to getting this.

T. A. Rosolowski, PhD:

I had fun too. I'm turning off the recorder at three o'clock.

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Chapter 05  A Graduate Focus in Health Psychology

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