THE WALL STREET JOURNAL - AUGUST 11, 2006

WORKING OUT YOUR ANXIETY

Wall Street Journal - Hannah Karp - What does your serve say about your relationship with your father? Our reporter on practitioners who combine therapy with physical activity.

For most tennis players, love means nothing. But Zach Kleiman wants to know what love means to you.

Mr. Kleiman is a professional tennis instructor turned therapist. From a court in Los Angeles (where else?), he works with as many as 50 clients a week on issues like anger management, addiction and narcissism -- all through the game of tennis. His techniques include talking to clients about their concerns during rallies, analyzing their shots for hidden aggressions and using drills like "Dad and Me," in which the client has to say whether he's hitting each shot to fulfill his own expectations, or his father's. "The ball is just a metaphor," says Mr. Kleiman, who refers to his work as "zennis."

Mr. Kleiman has no formal training and he isn't licensed as a mental-health professional. But he has built a thriving practice through referrals from a group of licensed therapists and by word-of-mouth.
He is one in a tiny pocket of mental-health practitioners who are combining physical activity and talk therapy. The methods range from strolls to more rigorous "Adventure Therapy" programs, which involve wilderness experiences like rock-climbing and camping. Atlanta psychiatrist Sheldon B. Cohen runs with his patients, while licensed counselor Geri Dube takes her clients on walks around Seattle.

But some prominent doctors are critical of the approach, saying that it can violate professional guidelines meant to establish boundaries and maintain confidentiality. Therapists have also found some real-world risks: Clay Cockrell, a New York social worker who walks with his clients, has witnessed a mugging in Central Park and an explosion during his sessions. Psychotherapist Terri Hengesh, who hikes with her patients in Northern California, has run into snakes on the trail. (If you encounter a snake while walking with your therapist, is it really just a snake?)

See a few of the methods some therapists are using that combine exercise and talk.

The alternative treatments come as mainstream therapists are under pressure, in part because of the success of drugs in treating mental illness. Patients are increasingly opting for medication over talk therapy. Nearly 15% of adults used an antidepressant at least once last year, according to pharmacy benefit manager Medco Health Solutions, up from 12% of adults in 2001. And while drugs are often meant to be used in conjunction with talk therapy, medication is serving as a substitute. A study published this month in the American Journal of Managed Care found that less than 15% of patients received the suggested level of follow-up care after starting antidepressant medication -- the U.S. Food and Drug Administration recommends weekly face-to-face visits in the first four weeks. Health insurers often cover just half of the cost of mental-health treatments, leading patients to drop out.

Scientific Benefits

A number of studies have documented the psychological benefits of exercise. While scientists have long known that a workout can temporarily boost serotonin levels and improve mood, the latest research shows that exercise can have a deeper and more lasting effect. One article in the American Journal of Preventive Medicine last year found a correlation between the intensity of exercise and a reduction in depression. A 2005 study published in the Journal of Neuroscience found that exercise increases the growth of neuronal brain cells, possibly elevating mood permanently. Advocates of the combined approach say that being active during the session helps patients to relax and open up, and some patients say they find it easier to talk while looking forward and walking, rather than staring the therapist in the eye.

Jeffrey Marsh is working through childhood trauma on the court with Mr. Kleiman. Dr. Marsh, a professor of psychology who has his own practice and is president of the Gestalt Therapy Institute of Los Angeles, a professional group for psychotherapists who marry Freudian analysis and other approaches, has referred more than 10 patients to Mr. Kleiman over the years. But he cautions that the sessions should supplement, not replace, conventional treatment. "It's not therapy, but it's very therapeutic," he says. (Dr. Marsh and other clients interviewed waived confidentiality and allowed their names and sessions to be put on the record.)

Zach Kleiman advises Theresa Yee Barker at the Studio City Tennis and Golf Club in Los Angeles.

Mr. Kleiman generally starts sessions -- at a rate of $90 an hour -- with a personal question such as, "What quality would you like to express more of?"

Patients' problems run the gamut. Brian Boyle, a 37-year-old TV writer from Seattle who has written episodes of "Friends," came because he was having trouble with a screenplay. (Mr. Kleiman says Mr. Boyle's 120-mile-an-hour serve speaks to the fact that "he likes to start things, but the aggression that he has at the beginning dissipates.") To help Mr. Boyle get in touch with his characters, Mr. Kleiman starts with a role-playing exercise.

"I'll do Walt, you do Ted," says Mr. Kleiman, referring to characters from the script. After a few silent hits back and forth, he says, "More Ted, please."

Jason Blum, a 37-year-old film producer, wants to discuss shame. He had just received a toy dump truck in the mail from a woman he had neglected to call after their second date. "I was quietly dumping her, but she was loudly dumping me. I'm ashamed that I couldn't take the initiative first," he says.

Couples come, too. John Peaslee, who had heard stories of Mr. Kleiman but was wary about doing something so "touchy-feely," signed up for lessons with his wife after she came home late and they got into a fight. "We were here for 10 minutes and Zach said to my wife, 'You have control issues,' and to me, 'You have intimacy problems.' The instructions were to play inside the box, and I kept backing up," says Mr. Peaslee, a 55-year-old TV producer and writer.

On a recent Friday, he and Mr. Kleiman play a game called "Alphabet." After every hit, the client must say a word that starts with the subsequent letter. Mr. Peaslee begins. "Aardvark. Bear. Cat. Dog."
"How'd you get to animals?" Mr. Kleiman asks.

"I don't know. I thought it had to be animals. I put locks on myself."
He moves on to more abstract words, and starts missing shots. "Rapid. Stupid. Travesty."

Combining therapy with nature and activity isn't new. In the late 1800s, Sigmund Freud walked with some of his patients through the streets of Vienna and even brought a few of them along on his vacations, says Jacques Barber, associate director of the Center for Psychotherapy Research at the University of Pennsylvania School of Medicine. In later years, Freud moved to an enclosed space to eliminate distractions. Still, up until the 1960s, when antidepressant medications became more common, people with symptoms of depression were often sent to rural retreats were they would garden, chop wood or stroll with doctors. Even today, therapy isn't limited to offices. A behavioral therapist might take an obsessive-compulsive patient into a dirty train station to confront their worst fears, while others take clients outside, to a park bench or garden.

A Dangerous Combination

However, some warn that combining sports and therapy can be dangerous. Dr. Barber says that engaging in sports could lead to "multiple relationships" between therapist and patient. "To maintain boundaries, people have to be very cautious," he says. "If you play tennis with them, where do you stop?"

Peter Kramer, a clinical professor of psychiatry and human behavior at Brown University and author of "Listening to Prozac," believes that an activity like tennis can add an unwanted element of competition. If a therapist takes too much pleasure in the sport, it can be a problem, he says, "since many patients have had parents who were very competitive, or who were more interested in themselves than in their children."

In New York, Clay Cockrell talks with a client.

Bernie Fleischer, 74, felt the sting of Oedipal defeat after one of his tennis sessions. The benefits administrator says that after admitting he was having trouble returning serves, Mr. Kleiman spent an hour hitting "unreturnable" serves at him. Mr. Fleischer was furious and quit for a while, but has since returned. Mr. Kleiman says the serves "were not unreturnable," and adds, "I trusted he could find his way out of the conundrum. I love that he got mad."

Many of the practitioners say it was an intuitive decision. Keith Johnsgard, professor of psychology at San Jose State University and author of "Conquering Anxiety and Depression Through Exercise," started walking with his patients when he realized that he was less anxious after working out with colleagues at lunch.

Mr. Cockrell in New York hoped to expand his practice by meeting busy patients at the office for a stroll at lunch or on the way home. Now he walks with five clients a day, at $150 for 50 minutes. He recalls "a great session" when a manhole exploded in front of him and a client, forcing them to realize that "you could be zapped at any time." Another time, Mr. Cockrell and a patient who wanted to be more assertive encountered a woman being mugged. "It was an opportunity to put this into action," he says. "We both started yelling and the thief ran off."

Mr. Kleiman started teaching tennis to friends at the age of 15. After graduating from college, he tried to make it as a professional player in Australia and New Zealand for a year, then returned home to resume teaching. He had always been interested in psychology, but says he discovered his current approach by accident. "I would tell people to watch the ball, but some part of me knew that wasn't working," he says. "So I started asking where they were looking." Today, he consults with seven licensed therapists and adheres to the same rules of confidentiality.
Not all of his students are prepared for his unusual approach. David Weinberg, who came on the recommendation of a friend to open his swing, says he was shocked when shortly into their first session, Mr. Kleiman asked, "Who hurt you?"

"I said, 'Excuse me? I don't want to answer that on the tennis court,' " recalls the 41-year-old music industry executive. He's continuing sessions, though -- he finds it helpful to focus on his mental state rather than formal technique.

Others yearn for a little more straightforward tennis instruction, which Mr. Kleiman avoids giving. (To him, serving is "initiating.") Carolyn Finger, 37, started seeing Mr. Kleiman to work through "body issues" and her mother's death. But, the media analyst says, "I'm hoping one day he'll tell me how to hold the grip."

Exercising Your Demons