Mind, Body, and Unexplained Symptoms

Mind and body are inexplicably linked. I suppose it is an artifact of the linearity of language and the way the use of language conditions our perception that we come to believe that body is somehow separate from the other aspects of our selves. I have an example. I came to have the opportunity to interview a woman who had defied medical diagnosis and continued to suffer. Her story is common. Many people feel poorly and defy diagnosis. Our medicalized system of beliefs (or stories) fail to match the stories people tell about their suffering. Pattern recognition by doctors just doesn't occur. Sandra had some confusing lab results as is often enough the case. Most of her laboratory studies, however, were normal. Her free T4 (a thyroid hormone) was low, though her total T4 levels and her TSH levels (thyroid stimulating hormone, which is high when the thyroid is not responding to the signals sent by the pituitary and very low when the thyroid is overactive) were normal. Her sedimentation rate (a measure of inflammation as it affects the red blood cells -- literally, how rapidly they settle to the bottom of a jar) was just slightly elevated, as was her platelet count (which is also seen in states of inflammation). Platelets are the small cells in the blood that facilitate clotting when we are cut. Her hematocrit (the percentage of red blood cells in a cubic centimeter of blood) was also minimally low. Hormonal studies showed a slightly low estradiol (an estrogen) but normal progesterone, estrogen to progesterone ratio, testosterone, and dihydroepiandosterone (DHEA). These are molecules that reflect the functioning of the pituitary through the reproductive system and the adrenal glands. Her night cortisol was slightly elevated, evidence of perhaps some stress and increased adrenal activity. Sandra's symptoms were varied, from vaginal dryness to a feeling of being severely stressed. She believed she was sensitive to chemicals (which are, of course, everywhere). Extra ovarian follicles (which release eggs to be fertilized) had been found along with irritation of the duodenum, the first part of her small intestine. Conventional medicine had offered her the usual medications to calm the intestine, which are called protein pump inhibitors. Seeing nothing else they could treat, they had offered her fluoxetine (originally marketed as Prozac) and had referred her to a psychiatrist, which had incensed her to no end. She believed all the doctors she had seen were incompetent to not discover what was wrong with her. Sandra had been seeing an acupuncturist for the past 8 months, believing that this treatment had improved her canker sores, but little else. She had also taken probiotics, which are tablets full of the healthy bacteria that line our intestinal walls. She had added the help of a reflexologist (person who treats the body by massaging the feet) who wanted to heal her stomach first and then her reproductive organs. The Chinese Medicine doctor gave her herbs for her menstrual periods which didn't help and gave her stomach pain. A nutritionist then altered her diet to eliminate all sugar, pork, spice, sauces, dairy, soy, and wheat, which also didn't help. Recently she had begun eating dairy and bread again and was no worse for the wear. She had even gained some needed weight as she was too thin even by body mass index standards. By the time I saw her, stomach pain was coming and going. The last few weeks of eating more rich food had bloated and constipated her, increasing her stomach area discomfort. Eighteen months previously a podiatrist had operated on her foot for pain there which the reflexologist blamed for the stomach and small intestinal symptoms, since the surgery was in that area of the foot. The reflexologist associated pain in her heel with the problems in her reproductive organs. However, Sandra couldn't tell if reflexology was changing anything. She had also taken Yaz and Accutane, on which any number of her symptoms could be blamed. Sandra graded her Chinese Medicine doctor as having earned a solid "B". No one else had earned a grade higher than a "C" and conventional medicine was a dismal "F". She was also taking a variety of supplements. What should she do? Sandra was an enigma to her health care providers. I asked her about the quality of her life over the past three years. "I'm so stressed," she said. "I'm so full of worry. I'm so high-strung. I worry all the time." I learned that she was a highly successful optometrist who was opening practices and employing other optometrists to run them all around the city. The more successful her business became, the worse her symptoms were. Then I asked Sandra is we could invite her husband to a meeting to help us with the inquiry into her symptoms. She agreed and he came to our next meeting. Daniel was a tall, handsome, muscular man. He confidently sat in the chair next to Sandra. Compared to her nervousness, his self-assurance and comfort was even more extraordinary. I asked Daniel what sense he made of Sandra's illness. "It's stress," he said. "She stresses herself over nothing. She worries continually and incessantly about the business, though it's never been better." Daniel, it turned out, was an accountant, who carefully administered the financial aspects of the business. He ran the numbers and was confident in how well the numbers were working. Sandra, on the other hand, was forever worrying about what could go wrong with the business. Success, in one sense, had "gone to her head". When she had nothing, she worried about nothing. The more she had, the more worries there were. Buddha, of course, told a story about this probably more than once, but the one I remember came on a lovely summer day in which he and his disciples were lounging in the shade beside a brook while a farmer frantically ran up and down the road looking for his lost cows. The monks had not seen his cows and knew not which way they had gone, so could not help. Over the course of the month they remained in that place, the farmer lost his cows several times. Finally, Buddha couldn't help but notice that cows were perhaps not a good thing to have. In my story about the world, Daniel was probably accurate since our loved ones usually know us pretty well. Excessive worry through the body's stress mechanisms produces inflammation, which is associated with dysfunction in just about every organ system from the ovaries to the adrenals to the bone marrow to the stomach to the heart. Pro-inflammatory molecules make us feel like we do when we have the flu but without the sneezing. They make us more allergically reactive. Stress and worry makes us tense which can lead to injuries. I explained this theory to a skeptical Sandra and an enthusiastic Daniel. Perhaps Sandra didn't need yet more medical tests and procedures which are in themselves stress-provoking. Perhaps, for the first time really in her life, she needed to learn how to be still. She needed to learn to relax. She needed to learn how to turn her attention away from all the possible negative outcomes and dwell on some of the very real positive outcomes or even to think about no outcome at all. The Harvard psychologist William James wrote that the one thing we can control about our brains is where we direct our attention. Sandra might need to learn how to direct her attention differently. What medicine does is primarily treat the end product of the inflammation with symptom suppressors rather than look to the source of the inflammation, which in this case, appeared to be excessive worry brought on by too much success! Of course it's confusing when we look at the body as if each part were totally separate. We look at nouns instead of verbs, organs instead of processes. When we think of process, we think of inflammation affecting multiple organs in a variety of ways that are as individual as the person herself. The hard sell is to convince people that their bodies respond to the events of their lives. We have been trained that an impenetrable wall separates body from life. So long as we believe this, our symptoms are mysterious and undiagnosable. As Sandra learned to worry less, her symptoms lessened. Eventually she was much more comfortable in both her body and her life. Diagnosis no longer mattered to her for she had an explanatory story that worked, that gave her a path to follow to feel better, and that had support in science, though not perhaps as much in culture

Narrative Practices for a New Year

It's New Year's Eve, almost 2012! The year the Mayans ran out of space to keep going on their calendar and had a good laugh about what people in the future would make of that! I wanted to begin the year talking about the narrative paradigm, which I have embraced wholeheartedly and hope to be helpful in its development. The narrative paradigm arises from the realization that all things human exist in the form of stories. Our brain stores and manages information in a storied form. We communicate most effectively with others through telling stories. We live our lives through the performance of roles that we come to understand through listening to stories that inform us about how we are supposed to live. We change through hearing stories about other people's lives and trying them on for our lives to see if we could do what the hero in the story did. Psychotherapy involves the negotiation of stories. In my practice, I've learned never to ask "Why?" I don't ask people why they do what they do. I assume that they, like me, haven't a clue. We like to ascribe motives to people and we imagine that they know why they do what they do. We wait breathless at the end of crime dramas for the suspect to explain why. We want a wrap up. We want to know their motive. We need narrative closure. We want to tie together the story into a neat package -- Bob killed Mary because she cheated on him and he was jealous, for example. However, my actual experience is that most of us (including me) don't have a clue why we do what we do. As children, when an adult asks us the "Why?" question, we try to make up an answer that will please or satisfy the adult or minimize our punishment. Instead I try to ask "How?" questions. "How does that work?" "How did you know to do that?" I've also learned not to give people advice. People have actually explored all the possible answers that I could imagine without being in their lives. They've already thought about everything I could suggest. The only possible good suggestions could come from other people in their lives who have known them for years, which a therapist never will. People don't need advice. Rather, they need assistance to explore what stories they have about how to live that keep them from following the advice that they already know they should follow. So, I try to find the story behind the position, belief, fear, stance, or attitude that people have that keeps them from changing. Rather than interpret other people's lives and stories, I try to maintain a stance of appreciative inquiry -- asking lots of questions from a standpoint of appreciating how well the person has negotiated their life and wondering how they were able to do as well as they did. I try to balance the positives -- to find positives in stories that are presented as all negative. Sometimes it's even important to find a negative in a story that's presented as all positive. My hero in all this is the character, Columbo, a detective who never stopped politely asking respectful questions until he solved the crime. There's no answers; just stories; no truths, just many perspectives. What's liberating about this? If we're shaped through stories and stories shape our brains (through in part our performance of the roles taught to us by those stories), then there are no diagnoses, no DSM (Diagnostic and Statistical Manual of the American Psychiatric Association) as absolute truth or fact (rather, just one more classification system that's more or less useful depending upon the circumstances and situation), no defective people, just stories that work better or worse depending upon the circumstances and the situation. Our job becomes helping people become aware of the stories that are shaping them and influencing them. Then we can learn how to change those stories. Let me tell you about a woman I am seeing. We began our work together because of her anxiety about her heart. She's had some coronary artery disease diagnosed, but not severe enough for treatment yet. She's in her late seventy's and was full of criticisms about her life and her value and how she lives. We began by exploring the stories about the critics in her life -- her father, primarily. She grew up as the only daughter of the law school Dean at a major Eastern university who doted on his sons and ignored her. The sons were expected to go to Law School and to become important contributors to the legal community. Girls got married and had children. This was the 1940's. Rivka's stories were all about her trying hard to get noticed in this family of men and never succeeding. Her mother had long before withdrawn into gin and tonics, the drug of that generation. Over time, I was able to construct a different story for Rivka -- one of being a heroine of the gender wars of the 20th century. Hearing my interpretation for the first time made her very uncomfortable. She had a visceral reaction in her gut and her chest. "Look at it," I said. "Your daughters had a very different relationship to gender roles than you had. They did what they wanted for work. They weren't limited to becoming nurses, teachers, or wives like you. You participated in the "Great War" that changed all that. Rivka had reasons to deflect my re-interpretation of her life. She saw herself as having had two marriages that hadn't worked, one of which was still current. Her first husband had been very much like her father -- partriarchal, domineering, controlling. That was the dominant paradigm (aka story) for how men behaved toward women in those days. I pointed out how Rivka had the courage to divorce him in a time in which divorce was uncommon and to create a new story for her daughters about gender relationships. Her second husband, while problematic in other ways, was not patriarchal, controlling, or domineering. Actually, he seemed the opposite. She had gone too far in the other direction. She viewed him as passive, weak, and indecisive. However, I pointed out that she had radically shifted the balance of power by becoming the stronger one in the relationship. This was a gender role triumph. She could be proud of her work as part of the "Great Gender War". She had more arguments about how others had been more visible and more important in changing gender roles; others like Gloria Steinem who seemed to singlehandedly transform gender in New England. "No," I said. "It was just waiting to change and she gave everyone permission to come out and do what they were already preparing to do. She just got all the credit for being in the right place at the right time. What about the countless numbers of people who fought in World War II. Not all of them got the Medal of Honor, but weren't all of them heroes?" Rivka had to agree. She had been a part of that story about the returning warriors from the second Great War. We continued to work on Rivka's writing the story of her life from the perspective of a great granddaughter, seven generations removed into the future. She was slowly coming to see herself as more heroic than she had ever thought and to see that her "Critic" was really the voice of her father's generation of men, an amalgam of all the men who sat around her father's exclusive, all-male club at the University, smoking their pipes, sipping their single malt whiskey, and sure of their supremacy in the world. Progress consisted of her coming able to laugh at that image. We accomplished that initially by turning them into animals, lounging in their suits at their club. Her father was a badger. His best friend was a wolverine. All the Ivy League men from her father's cadre became animals. Making people into animals is a good technique for seeing the story in which they are all living. Rivka was taking an upcoming training with a man that intimidated her. We turned him into a raccoon which made the whole issue hilarious. Here's an example of how narrative work addresses low self-esteem, especially the low self-esteem that an elder can have for herself at last portion of her life when she has judged herself by the stories of her birth time and place, despite the reality that all these stories have changed. The patriarchy has melted. Hilary Clinton is Secretary of State and Michelle Bachman can terrorize us with her radically conservative views as a potential President. The world of Rivka's childhood only exists in old movies. How is this important to her worries about her heart? That remains to be determined, but I suspect that being "hard-hearted" toward oneself can't be helpful. Compassion and forgiveness for ourselves matters, and maybe even to our hearts. In Cree, the word for fire translates literally as "the heart of a woman". Compassion and forgiveness is thought to warm the heart, which could symbolically melt the cholesterol plaques in her arteries. Of course, the better we feel about ourselves, the better we evaluate ourselves, the more likely we are to exercise, eat well, and do the other heart healthy behaviors that reverse arteriosclerosis. Be that as it may, the narrative approach is a lot more fun than diagnosing Rivka as having an anxiety disorder, which is what the DSM would do. The work we're doing is more productive for the last phase of life than being diagnosed, treated with drugs, or even an uninformed psychotherapy. She still needs to learn and practice more mindfulness (who doesn't?) and to live more in the present moment, but that become so much more possible when we feel good about ourselves. On a personal note, I am in Times Square for New Year's Eve along with over one million other people which couldn't be more exciting.

Reflections upon Teaching Statistics Again

This semester I find myself again in the enviable position of teaching statistics to psychology graduate students. My cohort is over age 30 and has not studied math for more years than we can count. So how do we teach them? I can tell you what not to do! First, don't assume they know anything, even what an average is! Assume no knowledge until proven otherwise! We don't currently have a placement exam, though I have recommended one now, since the assumption that undergraduate statistics has been retained has proven false. I am finding myself teaching basic ideas, dividing cake, flipping coins, telling them that statistics has to do with proportionality. Second, assume no interest, either! My second surprise was to learn how uninterested my students were in statistics. I suppose I should have known better since anyone with any interest would know something and these students largely knew nothing. To know nothing about statistics, as common as it is in modern life requires an active effort to avoid learning. I should have suspected this. We all have stories to explain our behavior and avoiding statistics is no exception. These stories included "I don't do numbers"; "Knowing statistics has nothing to do with being a good psychologist"; "I can't do math"; "My brain can't comprehend math"; and "I don't have time for this", among other good summary lines. Math education in North America is seriously flawed and biased against women. We know this. Malcolm Gladwell explored math education in Asia and discovered that most of the advantage that Asian students have in understanding math over their North American counterparts comes from their going to school around the entire year and not taking a summer vacation in which they forget what was learned the preceding year. Apparently Asian students didn't have to stop school to help their family with the planting, growing, harvesting, butchering, and other farm chores. Math education has changed, however, even if summer vacation is still observed. We now teach math visually and kinesthetically. We use Lego - to model probability distributions. We cut pieces of pie to teach children about fraction and percent. And, we try to make it interesting. To be most successful, science education has moved to problem-based learning. Except in the most conservative bastions of pre-med student screening in which courses are designed to fail more students than pass, we've abandoned rote memorization as a technique. One, there's too much to memorize. Two, no one remembers what they memorize after the test. Studies have shown that lectures using power point and other visual aids result in 15% the retention of knowledge that occurs when students work together in small interactive groups to solve a problem. Therefore, statistics is being approached as learning how to solve problems together, interactively. The problem solving approach more closely mirrors how science and math are really done and how they arose. The neat linear textbook with tight principles and theorems that people of my age encountered in high school geometry and algebra is an artifact. It's a story made up years later to explain what happened in a way in which it clearly never happened. Statistics, for example, was born in the gambling dens of France. Noblemen were losing their shirts (and estates) at the gaming tables. They came to mathematicians like Pascal and de Moivre to solve their problem. A famous initiating problem was, "what are the odds of rolling 4 sixes in a row with a die?". No one had thought about this before, so experimentation was required. The mathematicians rolled dice and collected data. They didn't actually go into a state of deep meditation and receive the answers from another dimension (though that's been known to happen in science and math as in the solution to the problem of the structure of the benzene ring or a recent development in the theory of black holes). They collected data and examined their results for patterns. This is what we humans do very well. They counted the number of times that each combination of dots on the dice appeared. Pascal invented a triangular table for predicting the number of times any number would occur given successively increasing numbers of rolls of the dice. Of course, it's called Pascal's table. In that table the expected number of times that a "3" for instance would appear in 20 rolls would be the sum of the two numbers above and adjacent (to the right and to the left) of the desired number. Wow, who knew that would happen! Then they could really inform the noblemen what their odds were of success. And, of course, we all know the answer -- don't gamble; odds always favor the house. This is one statistical result that almost everyone in North America has heard; though not many follow its advice. And, actually, there's another way to interpret the results, which I follow. If the odds of winning the lottery are quite small, then buying enough tickets to make a difference would be prohibitively expensive. Therefore, buy one ticket and ask the spirits (Forces, God, Ancestors, Lady Luck, etc.) to rig the game and help you win. This is my approach each week. It hasn't worked yet, either, but then, neither have I lost much money. The Gallup polling organization uses a similar approach. Instead of increasing the number of people they poll over 4,000, they work at reducing the bias and the error from how they select the people which they poll -- a much less expensive strategy. Statistics, then, was discovered as a way to answer practical questions. At the Guinness Brewery, for example, a statistician named Gossett invented a way to reduce the number of beers that had to be sampled (drank!) to do quality control. Apparently, the makers of Guinness were so incensed that anyone would suggest that any of their beers were not perfect, that they demanded that Gossett publish his results under a pseudonym. He chose the name Student -- hence, Student's t-test. Using the t-test and it's t-table, Guinness could waste fewer beers on their employees and still achieve an acceptable degree of quality control. The problem, I discovered with my students, is that they wished certainty. They wanted to know exactly how things worked including the basic principles for going from a to b to c before they attempted to solve any problems. I suspect this is a function of age. My younger acquaintances handle problems very differently. If given new software, for example, my son tries everything to see what it does. He'd never consider reading a manual. He just plays until he feels like he knows what it does. He doesn't have the belief that many people my age have -- that we will somehow screw up things. He comes from the generation that simply knows that pushing the "reset" button will solve everything and we just start over again. My generation is not so sure of that. Nevertheless, teaching statistics has generated some philosophical ideas for me. First, we live in a probabilistic universe as much as we try to avoid thinking about it. The future is not determined. In fact, the most parsimonious theory of quantum physics predicts that every time we make a decision our universe divides into two copies -- one in which we leave New York to open up a restaurant in Santa Fe (see the musical, Rent) and one in which we don't. The possibilities are endless giving an almost uncountable number of parallel universes arranged in some probability distribution. Some parallel universes are more likely than others. For example, there can't be too many parallel universes in which I won the lottery since it hasn't happened yet. For every parallel universe in which I do win the lottery, there must be many in which I don't. Some occurrences are more likely than others. Here's where probability enters. I say to my newest client, what are the odds that your Toyota Camry is not a hovercraft and won't stay afloat if you drive it over a cliff. He has to think about this for some time because he was quite convinced of its anti-gravity drive and its cosmic multi-dimensional nature. Finally he agrees that there might be some parallel universes in which it's only a car and that it might behoove him to be aware of which universe he's in when he turns on the ignition. (Seeing more than one dimension at a time is often problematic for those without the training of a holy person or a culturally sanctioned inter-dimensional traveler.) So, many of the forces in our lives are random and we do what we can to rig the outcome. We do this through visualizing the probable future in which we wish to arrive, through prayer, through taking action when we can envision what to do, and more. Many of my patients are patients because they spend much of their time visualizing the most negative outcome that could happen. As Mark Twain once said, "Now that I'm old, I've lived through countless disasters, most of which never happened." Many of my patients spend hours each day imagining probable futures in which the direst events transpire. My job is to help them redirect their attention. I do believe that their visualizing in this way increases the likelihood of negative (from their value system) events happening to them, but I don't know how much. I also believe that prayer increases our likelihood of being pulled into the probable future into which we hope to arrive, but, again, I'm not sure how much. It's uncertain. I'm more certain that exercise increases my likelihood of staying healthier for longer, but it's certainly no guarantee. A myriad of other random forces could intervene. That's why it's important to me to express gratitude each day for my life and my health and all my many blessings and to not dwell too long on what I don't have but to focus on what I do have. Mark Twain also said, "The easiest way to be happy is to be content with what you have." I'm not a statistician though I enjoy learning. I have used statistics extensively in my research work and I appreciate the beauty of numbers and equations. I confess to not know fully the basis for every technique that I use. I know enough to get by, and, actually, learn more and more every time I teach statistics and every time I read about statistics. Learning, it turns out, is a life-long process. We've done a disservice to students by assisting them to feel that they can actually know a field or a subject. Just when we think we know something, the rug gets pulled from beneath us and all of the old concepts are null and void. Many of us avoid this by pretending that the rug is still there. For example, nearly everyone I meet believes that low levels of serotonin in the synaptic cleft in the brain causes depression even though we've known for years that this isn't true and the drug companies get fined regularly for implying it in their ads. Yet, it's a story that simplifies the complex, generates an air of certainty, and certainly sells drugs, so it remains part of the general knowledge base. It's a story that serves regardless of its lack of validity. What I can't do, apparently, is to give my students an interest in numbers. I've tried such things as using the Beastie Boys in calculating confidence intervals, discussing probability from the standpoint of the Cat in the Hat, and analyzing a database with them of meditators in Los Angeles trying to affect the growth rate of bacteria in Oakland through intent. I thought this last exercise would be really exciting, but no one even came to that lecture (since it wasn't part of the homework). It does, by the way, turn out that meditators in Los Angeles can influence the growth rate of bacteria in Oakland, and, thanks to the need to entertain my students, I will get to be part of a publication about that finding, so boring statistics students isn't all bad. What worries me, however, is how rigged research is. The knowledge generating empire is set to crank out certain kinds of knowledge that matches its biases. Funding will go to those who comply with the invisible rules for what you can study. Some of us at the margin find ways to do small studies to challenge this status quo. We don't typically score the large grants to do big randomized controlled trials because the questions we ask are too weird. Good questions related to drugs' effectiveness compared to placebo or sometimes the effectiveness of cognitive behavior therapy for specific (and relatively minor) conditions, but a study of psychotherapy and healing for psychosis, for example, is probably not going to get funding. Nevertheless, I can do small studies at the margins and even publish them as I have been doing and thereby support a small, but hopefully growing number of people who think like me. I wish my graduate students had this desire and interest, or even the interest to critique the available research to understand how it's rigged. My favorite example currently of this rigging is the study that facilitated the FDA's approving the drug, quetiapine, for monotherapy for bipolar depression. The study requirements meant that to be a suitable candidate, the participants could have never considered suicide, never used a substance of abuse, have no other mental health or medical problems, and so on. It took 43 academic centers to recruit just under 250 patients with bipolar depression that met this description. I believe we could help this population with almost any intervention and show better results than placebo, including gluten-casein free diets, reiki energy healing, or homeopathy. They certainly don't match virtually any of the patients I routinely see in my office who do misuse substances, consider suicide, and have a host of other problems. Just like my clients, my students feel only average and believe that they would do better with a great teacher. Unfortunately, I'm an average teacher looking for great students in the same way that I'm an average healer/clinician looking for the best patients. Because I'm not the one to change! Effort must be made and many students, like many patients, don't want to make that effort. We'd all prefer to be passively entertained and just learn or heal without having to show up and do the hard work of focusing and shifting our attention and trying things that are outside our comfort zone. One of my current patients believes he's invisible and will not do anything to increase his visibility. Consequently, he spends a lot of time sitting in his mother's basement -- one way to become invisible. The hard work, in teaching statistics or doing healing or medicine is inspiring people to believe that they can make a difference in their lives, their learning, their outcomes, their level of suffering, and to take action to do so. Here is where story emerges. We need good stories to help people move outside their comfort zone. I'm looking for better stories for motivating students to learn statistics. I'm thinking that quantum physics and Heisenberg's Uncertainty Principle coupled with the Quantum Zeno Effect is the way to go. Mystical physics is usually a good source of inspiration as we say in the movie, "What the bleep"". Maybe this will work for clients as well. Therefore, I conclude, that we should all learn more quantum physics, and that's all I have to say about that.

Reflections upon the Transition to Private Practice

Just over two months ago, I left the community mental health center where I worked in New York to begin private practice in Vermont. I wanted to reflect upon the differences I am finding between a private practice model and the community mental health center model. Of course, New York and Vermont are very different places. One feels this on crossing the border. Suddenly, everything is organic. Even the gas stations present fair-trade organic coffee and have a section of Vermont products, from maple syrup through beer and wine. This morning I stopped at a gas station in the small town of Hartland, Vermont, which offered up a dazzling array of organic Vermont products including locally brewed beer. A short story will explain this well. A man came to see me who was feeling like killing himself. He was sad all the time and short-tempered. He claimed that he wouldn't act on his wishes, because of his son, for whom he was the sole parent. I believed him and we made an agreement that he wouldn't attempt to harm himself. He had already wisely given his hunting rifle to his brother (this is an important question in Vermont; whereas in New York, it was more about the hand gun!). I started him on two medications -- 25 mg of desipramine and 2 mg of aripiprazole. I chose the desipramine because he showed elements of difficulty paying attention and concentrating, and this drug had once been used for Attention Deficit-Hyperactivity Disorder. He also was not sleeping and desipramine is known to make people sleep, at least until they adjust to that particular side effect. He was 40 years old and athletic and I wasn't worried about any of its effects on the heart as I would have been with an older person. I chose aripiprazole because he was excessively fearful and suspicious. He thought people were whispering about him when he left the house, so he avoided leaving the house. He worried that someone was inside the house at night, so he compulsively checked under all the beds and looked in every closet before lying down to sleep. He heard buzzing voices but couldn't make out what they were saying. He had a tremendous sense of impending doom, thinking that at any minute something terrible would happen and he would be struck dead. He worried that this would be at the hands of someone he had wronged, though he couldn't imagine who that would be or that it would be a random act of nature, such as a lightning bolt or a tree falling on his head. I also chose aripirprazole because gaining any weight was unacceptable to him given his athletic tendencies, and most of the other similar drugs result in weight gain. I gave him his prescriptions and made an appointment for one week later. What's different about this scenario? In New York, he would have waited for several weeks to see me. He would have had to have an interview with a social worker first and would have then been sent to me for medication management. I would have had 15 to 30 minutes with him instead of the hour that I spent. I could not have seen him again for two months and would have had to have him see a nurse in several weeks for follow-up. In New York, private psychiatrists are paid $7 per visit (so I was told by a private psychiatrist in Rochester) by New York Medicaid, which makes them unwilling to see Medicaid patients. The community mental health center, in contrast, because it is a designated facility by the Office of Mental Health, receives $172 per visit (according to one of the administrators there). Vermont Medicaid, in contrast, pays about $110 for the first visit. Afterwards, it pays about $60 for a medication visit and up to $110 for medication management combined with one hour of psychotherapy. I could afford to see him every week. In fact, I make more money in private practice from Vermont Medicaid than I made working for the community mental health center and I get to see people for an hour instead of 15 minutes and the State of Vermont actually pays less overall than the State of New York did to care for a similar man. I saw this man every week for three weeks. We adjusted him medication to a dose of 50 mg of desipramine and 5 mg of aripiprazole. He is feeling much better. This is a "born in the hills" kind of man. He had never been exposed to psychotherapy. He probably didn't know we were doing cognitive behavior therapy (what I call Buddhism 101). On the MYMOP2 scale (My Medical Outcome Profile) which I use to track improvement, his level of distress had dropped from the top number of 7 to a number oscillating between 4 and 5. At the next visit, he asked me if he could come every other week. "So long as you're not thinking of killing yourself," I told him. "I'm not," he replied. "Well if you start thinking that way again," I said, "you'll have to go back to every week." "That's a deal, doc," he said. In relatively short order, we had moved him from crisis level to a more mundane level of psychiatric urgency. I would argue that this was much more cost effective and health effective than what could have been done within the constraints of the community mental health system in New York. He has my phone number and can call me if problems arise. I could work him into my schedule the same day if need be. So why wouldn't New York want to encourage private practice? Since I didn't know the answer, I asked a number of New York psychiatrists and mental health providers. The most common initial answer was that the State of New York doesn't trust us not to "rip them off", to say that we're providing care, and not do it. With the community mental health system, they can come anytime and audit charts and demand money back. The volumes are sufficient that the money they get back is substantial. With private practitioners, the volume would be lower and auditing visits would be less cost effective. So New York is willing to waste money in order to get money back at the cost of less effective care. There may be other reasons, too, and those I do not know. I have noticed another difference between New York and Vermont medicine. In Vermont, family doctors are readily willing to take over prescribing psychiatric medicine for patients if they know they have support and can call when there is trouble. In New York, I could only convince one family doctor to do this, thereby resulting in a slew of 15 minute appointments every three months for people who were stable and could have seen their family doctor. Personally, I do not believe that this man's improvement was all medication. I believe that our relationship played an important role, including his knowing that I was there for him, that he could call me and I would respond. I "held space" for him, which is radically different from what happens when a patient sees a different practitioner on every visit. The theory is that all doctors should practice the same and that relationship shouldn't matter compared to the powerful drugs. But most of us know this isn't true. Psychotherapy outcome shows that relationship is crucial and that it does matter very much in outcome, perhaps being the primary factor. I completely believe in the power of placebo, or what Herbert Benson of Harvard calls the "self-healing response". Perhaps placebo is our most powerful medicine, but placebo operates best in the context of a relationship. It's harder to believe that a mental health center cares in the same way as it is to believe that a single human being (me in this case) cares. My client lives with his new girlfriend and some of his distress relates to their relationship. In time, I hope to convince him to bring her with him. I hope to engage them in learning how to dialogue with each other. I am convinced that healing occurs through dialogue, through the kind of dialogue that he and I had and through the kind of dialogue that he and his girlfriend could learn to have. Currently, I suspect that they talk at each other and not with each other. Hermans and Hermans-Konopka have written a powerful book on Dialogical Self Theory in which they explore these concepts more fully than I could have articulated them prior to reading their book. They have spent more than one life time (combined) studying dialogue and have come to an understanding that dialogue changes each participant in a conversation. Monologue does not . Mostly I fear we talk in order to make our point and not in order to share with another. This idea was very apparent to me at a weekend conference I just attended -- the 28th International Conference for the Scientific Study of Shamanism. I watched people interact in the "discussion" sessions held after each series of talks. Mostly people asked questions in order to state a point. The person asking the question did not really want an answer from the presenter and the presenter had a point to express that often ignored the gist of the question. I thought that we need dialogical sessions rather than questions and answers, which is part of the old paradigm in which an expert knows something that we need to absorb. Having read Hermans and Hermans-Konopka's book, I am trying even harder than before to listen carefully and to find what points of agreement even with those who disagree with me. My talk at the conference was about the healing power of community and particular the role of the shaman (I call them intercessors, since shaman is a Telengit word from a particular people in Siberia that translates as spiritual healer). I talked about how we couldn't heal by ourselves if everyone around us believed that we couldn't get well. We needed to convince all those around us that we can heal and that we will heal and perhaps are even already well. This is what a good intercessor does, I said. He or she convinces others that the patient can get well. These others include spiritual beings as well as actual living relatives and friends. This is what I tried to do for my client, though indirectly, for he has not brought any of the members of his social network to my office. A Buddhist scholar took issue with me. He argued that people can change all on their own with enough work, though slowly. I completely agreed with him. I just made the point that many of my clients are ill with life-threatening illnesses or serious psychological suffering and don't have the time to retreat from life or to learn the contemplative paths, though that would be wonderful for them and very healing. He was satisfied and we could continue to find more points of agreement. I learned through self-reflection that our first impulse (mine, at least) is to listen for how we disagree than to explore how we can both be right. I wish New York would do that -- would explore how private practice and community mental health could both be right. I think everyone would benefit were that to happen. A short story will explain this well. A man came to see me who was feeling like killing himself. He was sad all the time and short-tempered. He claimed that he wouldn't act on his wishes, because of his son, for whom he was the sole parent. I believed him and we made an agreement that he wouldn't attempt to harm himself. He had already wisely given his hunting rifle to his brother (this is an important question in Vermont; whereas in New York, it was more about the hand gun!). I started him on two medications -- 25 mg of desipramine and 2 mg of aripiprazole. I chose the desipramine because he showed elements of difficulty paying attention and concentrating, and this drug had once been used for Attention Deficit-Hyperactivity Disorder. He also was not sleeping and desipramine is known to make people sleep, at least until they adjust to that particular side effect. He was 40 years old and athletic and I wasn't worried about any of its effects on the heart as I would have been with an older person. I chose aripiprazole because he was excessively fearful and suspicious. He thought people were whispering about him when he left the house, so he avoided leaving the house. He worried that someone was inside the house at night, so he compulsively checked under all the beds and looked in every closet before lying down to sleep. He heard buzzing voices but couldn't make out what they were saying. He had a tremendous sense of impending doom, thinking that at any minute something terrible would happen and he would be struck dead. He worried that this would be at the hands of someone he had wronged, though he couldn't imagine who that would be or that it would be a random act of nature, such as a lightning bolt or a tree falling on his head. I also chose aripirprazole because gaining any weight was unacceptable to him given his athletic tendencies, and most of the other similar drugs result in weight gain. I gave him his prescriptions and made an appointment for one week later. What's different about this scenario? In New York, he would have waited for several weeks to see me. He would have had to have an interview with a social worker first and would have then been sent to me for medication management. I would have had 15 to 30 minutes with him instead of the hour that I spent. I could not have seen him again for two months and would have had to have him see a nurse in several weeks for follow-up. In New York, private psychiatrists are paid $7 per visit (so I was told by a private psychiatrist in Rochester) by New York Medicaid, which makes them unwilling to see Medicaid patients. The community mental health center, in contrast, because it is a designated facility by the Office of Mental Health, receives $172 per visit (according to one of the administrators there). Vermont Medicaid, in contrast, pays about $110 for the first visit. Afterwards, it pays about $60 for a medication visit and up to $110 for medication management combined with one hour of psychotherapy. I could afford to see him every week. In fact, I make more money in private practice from Vermont Medicaid than I made working for the community mental health center and I get to see people for an hour instead of 15 minutes and the State of Vermont actually pays less overall than the State of New York did to care for a similar man. I saw this man every week for three weeks. We adjusted him medication to a dose of 50 mg of desipramine and 5 mg of aripiprazole. He is feeling much better. This is a "born in the hills" kind of man. He had never been exposed to psychotherapy. He probably didn't know we were doing cognitive behavior therapy (what I call Buddhism 101). On the MYMOP2 scale (My Medical Outcome Profile) which I use to track improvement, his level of distress had dropped from the top number of 7 to a number oscillating between 4 and 5. At the next visit, he asked me if he could come every other week. "So long as you're not thinking of killing yourself," I told him. "I'm not," he replied. "Well if you start thinking that way again," I said, "you'll have to go back to every week." "That's a deal, doc," he said. In relatively short order, we had moved him from crisis level to a more mundane level of psychiatric urgency. I would argue that this was much more cost effective and health effective than what could have been done within the constraints of the community mental health system in New York. He has my phone number and can call me if problems arise. I could work him into my schedule the same day if need be. So why wouldn't New York want to encourage private practice? Since I didn't know the answer, I asked a number of New York psychiatrists and mental health providers. The most common initial answer was that the State of New York doesn't trust us not to "rip them off", to say that we're providing care, and not do it. With the community mental health system, they can come anytime and audit charts and demand money back. The volumes are sufficient that the money they get back is substantial. With private practitioners, the volume would be lower and auditing visits would be less cost effective. So New York is willing to waste money in order to get money back at the cost of less effective care. There may be other reasons, too, and those I do not know. I have noticed another difference between New York and Vermont medicine. In Vermont, family doctors are readily willing to take over prescribing psychiatric medicine for patients if they know they have support and can call when there is trouble. In New York, I could only convince one family doctor to do this, thereby resulting in a slew of 15 minute appointments every three months for people who were stable and could have seen their family doctor. Personally, I do not believe that this man's improvement was all medication. I believe that our relationship played an important role, including his knowing that I was there for him, that he could call me and I would respond. I "held space" for him, which is radically different from what happens when a patient sees a different practitioner on every visit. The theory is that all doctors should practice the same and that relationship shouldn't matter compared to the powerful drugs. But most of us know this isn't true. Psychotherapy outcome shows that relationship is crucial and that it does matter very much in outcome, perhaps being the primary factor. I completely believe in the power of placebo, or what Herbert Benson of Harvard calls the "self-healing response". Perhaps placebo is our most powerful medicine, but placebo operates best in the context of a relationship. It's harder to believe that a mental health center cares in the same way as it is to believe that a single human being (me in this case) cares. My client lives with his new girlfriend and some of his distress relates to their relationship. In time, I hope to convince him to bring her with him. I hope to engage them in learning how to dialogue with each other. I am convinced that healing occurs through dialogue, through the kind of dialogue that he and I had and through the kind of dialogue that he and his girlfriend could learn to have. Currently, I suspect that they talk at each other and not with each other. Hermans and Hermans-Konopka have written a powerful book on Dialogical Self Theory in which they explore these concepts more fully than I could have articulated them prior to reading their book. They have spent more than one life time (combined) studying dialogue and have come to an understanding that dialogue changes each participant in a conversation. Monologue does not . Mostly I fear we talk in order to make our point and not in order to share with another. This idea was very apparent to me at a weekend conference I just attended -- the 28th International Conference for the Scientific Study of Shamanism. I watched people interact in the "discussion" sessions held after each series of talks. Mostly people asked questions in order to state a point. The person asking the question did not really want an answer from the presenter and the presenter had a point to express that often ignored the gist of the question. I thought that we need dialogical sessions rather than questions and answers, which is part of the old paradigm in which an expert knows something that we need to absorb. Having read Hermans and Hermans-Konopka's book, I am trying even harder than before to listen carefully and to find what points of agreement even with those who disagree with me. My talk at the conference was about the healing power of community and particular the role of the shaman (I call them intercessors, since shaman is a Telengit word from a particular people in Siberia that translates as spiritual healer). I talked about how we couldn't heal by ourselves if everyone around us believed that we couldn't get well. We needed to convince all those around us that we can heal and that we will heal and perhaps are even already well. This is what a good intercessor does, I said. He or she convinces others that the patient can get well. These others include spiritual beings as well as actual living relatives and friends. This is what I tried to do for my client, though indirectly, for he has not brought any of the members of his social network to my office. A Buddhist scholar took issue with me. He argued that people can change all on their own with enough work, though slowly. I completely agreed with him. I just made the point that many of my clients are ill with life-threatening illnesses or serious psychological suffering and don't have the time to retreat from life or to learn the contemplative paths, though that would be wonderful for them and very healing. He was satisfied and we could continue to find more points of agreement. I learned through self-reflection that our first impulse (mine, at least) is to listen for how we disagree than to explore how we can both be right. I wish New York would do that -- would explore how private practice and community mental health could both be right. I think everyone would benefit were that to happen.

Accountability

I have recently become more aware of the dialectic between accountability and its lack. It's difficult to find a word for the lack of accountability that situates itself in easy and direct opposition to accountability. Perhaps synonyms would help. What I am calling accountability also resembles self-agency or the sense that we can do something to improve our situation, whatever it is. In the community mental health clinic where I have been working, the majority of the patients lack accountability or self-agency. Biomedical psychiatry has certainly facilitated that attitude and I expect we have had the most negative impact upon the poor for our attitudes reinforce their powerlessness. The wealthier classes come with a sense that we can do something to change our circumstances if only to throw money at it. Most of my patients believe that they are the victims of an illness that has caught them in its grip, much like a person might contract tuberculosis, lupus, HIV, or arthritis. They are not responsible for regulating their moods, for controlling their impulses, for their anger, for their sadness, for their actions. Their behavior is the result of their illness. Nothing can be attributed to them except in the sense of acknowledging the existence of illness. Of course, many have grown up in homes (or in several homes or in no home) in which emotional regulation was rarely achieved. Extremes of emotion were usual and common with family members continually reacting one to the other. No models existed for self-soothing or self-regulation. My patients expect me to provide them with a drug to regulate their moods and emotions, to make them feel "normal", though few can say what "normal" would feel like. The drugs rarely do this so they spend years searching for the "right" combination. Every new patient is sent for a medication because that's what we do, we prescribe drugs. Occasionally the drugs work (or seem to work, for the effects of placebo are also very powerful). Mostly, they don't accomplish what people want them to do. The rage this week has been bipolar. People have come to believe that if one is happy and sad in the same day, one is bipolar. Psychiatry has come to agree with this. Previously we called happy and sad in the same day "emotional lability", meaning one's emotions went up and down, sometimes unpredictably. It was a non-specific finding; not a criteria for bipolar disorder. That was before we invented the bipolar spectrum, in which every anyone can be a bit bipolar. We call it Mood Disorder, Not Otherwise Specified, or Bipolar Spectrum Disorder. Once upon a time, bipolar disorder was reserved for people who stayed up all night for days on end with indefatigable energy and disorganized creativity and then crashed with many variations on this theme, including or not including being psychotic. The label of "bipolar" used to be more difficult to earn. Here's one of my patients. She feels miserable. She spends her time at home, watching television. Her husband works. She doesn't go out. She has no friends. She feels anxious. Going outdoors makes her more anxious. Going into public places makes her very upset. In our first session, I explored her options, for there were many in the city. The Mental Health Association offered many free classes -- yoga, t'ai chi, chi gong, writing, painting, drawing, dance, and so on. Various churches in the area had healing circles, prayer circles, discussion groups, and so on. Exercise can be free, though joining a gym has its advantages. Meditation can be learned for free in a variety of settings. What was she willing to try? Nothing was the answer. She didn't like groups, she didn't like people, she didn't like to sweat, she couldn't meditate when she was feeling anxious, and she hadn't done the behavioral experiment I had recommended. An added calculation existed -- that she wanted to be approved for further disability. Where had my voice gone? Where was that voice that said that she could take action against this problem and by opposing, end it (to paraphrase Hamlet)? Here is the problem with once weekly psychotherapy visits, though most of my community mental health center patients are lucky to come once per month (they are usually scheduled for twice monthly and miss once). In weekly psychotherapy sessions it's hard to be heard amidst the cacophony of voices that is the person's life. In one hour once per week, it's hard to make a difference. Sometimes we do, and that's usually when the person does the behavioral experiments we suggest and external situations have changed to facilitate improvement. How is it that sometimes an idea will take hold when other times it won't? Recently also I saw an 18 year old who was threatening to kill herself to get the attention of her lover who had ditched her. It was a country music song gone all wrong. My client believed that the best way t show her lover how much she was hurt was to kill herself. "What if she doesn't notice?" I asked. That left her flabbergasted. "Of course, she'd notice. Maybe I'd even do it in front of her house." "But what if she thinks differently from you," I said. "What if she thinks people who commit suicide are stupid and you just confirm how smart she was to leave you?" "That's crazy" said my client. "No," I said. "A lot of people whom you haven't yet met, think this way" Through my questions and her responses, I was able to create uncertainty for her that she could accomplish her goal through suicide. Then she asked me what I would do, which I thought was progress. Immediately inspiration struck (or probably spirit guidance). I said, "I'd put up a facebook page dedicated to showing the world how miserable she's made you. That would be far more effective than killing yourself because you get to comment. You can still watch if you're dead, but it's much harder to keep posting and commenting and putting up more sorrow and suffering. You could be the most pitiable person on facebook! My client really liked this idea. She took to it immediately. She stopped thinking about killing herself. She had a new goal -- public display of pitifulness, at least until her girlfriend noticed! Through doing this, she learned that she could have an impact upon her emotions. She felt better as she worked away on her facebook page. She could change how she felt! That was dramatic news to her. I saw another patient in a family of bipolar (a new kind of bear, I suppose). For everyone in the family, all manner of bad behavior could be excused by attributing it to bipolar. Probably should be capitalized! My client's 14 year old sister was reliably calling the police to report domestic violence against her whenever she wanted to spend the weekend in the city. She would be taken to the group home downtown and then she could slip out and attend whatever concert or event she desired. My client was agonizing over the impact that all these arrests were having on her parents. In a puzzled way, I wondered why she didn't just bring her sister into town for weekends and save everyone a lot of hassle. For reasons I don't fully understand, she thought this was a brilliant idea. The calls to 911 stopped and the younger sister had her social life back (they lived on a farm some distance from the city). I don't know how it is that a question will sometimes change everything, but it does. And sometimes, no amount of questions or suggestions will make a budge. It's mysterious, how this happens. We are led back to stare uncertainty in the face. Everything is uncertain. What is certain, to me, is that we have some influence. Victor Frankl wrote eloquently about this in Man's Search for Meaning, telling how people had found some small sense of efficacy or agency in the German concentration camps (where he had been). The task is to find a way for people to realize they can do something to influence their world for the better. Furthermore, we must help people to be comfortable living saturated by uncertainty. A friend's niece epitomized this. Her niece invented certainty even though she knew that her plans would be forced to change. The creation of plans relieved her anxiety about uncertainty. We have to find ways to live with and embrace uncertainty. That is our next task.

Reflections After Sundance No. 2, 2011

This is the third summer in which my partner (a therapist) and I have danced in two separate sundances. We are part of a small number of people who are called to dance twice, because one dance leaves us feeling unfinished. Somehow, dancing twice feels like enough. It offers opportunities for accelerated growth and learning -- a chance to put into practice quickly what we have learned in our first dance. Our second dance is shorter, a three-day dance, and it is smaller. It is a family dance, handed down from an inspired leader. It has one-third the number of dancers as in our other dance, but we are an intense group, ferocious in the dance, and it is no less difficult than the first. At this dance we meditated on the idea of the dance as an embodied metaphorical struggle in which the suffering and deprivation are physical metaphors for the suffering of life. Hunger and thirst offer themselves as symbols for our struggles with money, time, pressures and responsibilities. The challenge to keep dancing in spite of this suffering reminds us of the difficulties we face in situations where we cannot stop or walk away. When we face a serious illness, when we face tension in life, trials, caregiving for someone suffering, the legal system or adversarial family members, we need models for how to carry through. Sometimes, the idea that we must keep going and triumph over adversity feels unbearable. We want to quit, we want someone or something to make it stop. We plead and make bargains with the spirits; we cover our heads, cry, and rail against circumstances. But then we realize that it's not up to us. The duration, the extent, the severity, and the outcome are not ours to decide. So then, the question becomes how to keep dancing in spite of this knowledge, without being discouraged. Indeed, we must discover how to rise to the best of ourselves, to exemplify courage in adversity. The dance is life. Can we face the circumstances with grace? Rising to the occasion, somehow being present and mindful in the face of the suffering is part of the task. So we dig deep and find in ourselves that place where we understand that we are truly not in control. Indeed, any effort to try to bend circumstances in our favor only leads to more suffering. The more we long for the dance "round' to stop, to get off our feet, the longer it seems before the chief signals the drummers to stop. The more we think about the food and water we will receive on the third day, the hungrier and thirstier we become. This year, we learned that giving ourselves over to the flow of the dance, expressing radical faith that we can survive the suffering, helped to spare us the pricks of pain that come with expectation. The metaphor suggests to us that life comes with suffering, whether through our own actions or those of others around us. We can choose to face the suffering with as much courage as we can muster, or with as little. In the end, it is our choice to see it as an event for spiritual learning or as an unfair insult from the gods. We can open ourselves to learn about it, or we can try to run and hide. Once we embraced this, we felt much better. We discovered that the mindset we used to embrace uncertainty and give up on the idea that we could know what was going to happen next could be applied to other things. We broke down the technique. One simple question we had asked was, what else do I have to do right now? Actually, nothing, we realized. We were scheduled to be there, and there was nowhere else to be and nothing else to do. Whatever happened or didn't happen, it wasn't going to change the amount of time that we were scheduled to be here. So, we might as well relax and just be here fully. That worked well. Also, finding was to stay in the present and not anticipate what would happen next or later in the day worked well. We focused on small moments, watched nature, clouds, the elders as they discussed the dance (and, to torment us, the bacon and eggs they had had for breakfast). We became aware of small sensations, the way our feet felt on the ground, the moment when we were given some herbs to chew -- a tablespoon of licorice root tasted like a three course dinner. Afterwards, we realized that put together, these are basic principles of mindfulness. Basic principles are sometimes difficult to learn but Sundance provided us with a laboratory in which we could learn these principles and apply them to our immediate situation. Having done that, it became easier to generalize these lessons to other life situations. When I feel impatient for something to finish, I can remember my Sundance experience, take a deep breath, and relax into the moment. When my partners want things to hurry up, she can remember Sundance, and remind herself that the day passes in its own time and to enjoy the moment, because the moment will soon be gone. These can appear to be trivial insights, but when they are embodied, they are profound. Sundance gives us the opportunity to cultivate the embodied awareness of the present moment in a way that lasts into future moments and allows for positive and permanent change. Of course we want to mitigate unbearable suffering. As health care workers we are bound to reduce or at least not cause more suffering than is necessary. But psychotropic medications, narcotics, street drugs of choice present an idea to us that life can be lived without suffering. Of course they have their place. But in some cases, they help to create an impression that "normal' life is lived in a state of emotional numbness, that emotions are simply too hard to feel, that life circumstances simply come with too much suffering. It seems to us that we do a disservice to people when we unwittingly endorse that perspective. Perhaps it is the job of life to learn how to suffer a little. The word to suffer means "to undergo'. We have created a mental health system where a "successful' outcome is when a person spends their days watching television, drinking coffee and smoking, rather than annoying us with their struggles to negotiate the world. At this year's second Sundance, we wondered if, perhaps as health care workers our jobs could include an aspect of education around the management of suffering. Barbara and I will be at Rowe Conference Center, September 16-18, 2011, in Rowe, Massachusetts, for further dialogue and experiential learning on these issues and the importance of working with story. For more details, see http://www.rowecenter.org or http://www.mehl-madrona.com. ; Also, related to these topics is a forgiveness workshop that Coyote Institute will be sponsoring with Olivier Clerq, September 9-11, 2011, in Brattleboro, VT. For more details, see http://www.coyoteinstitute.us. ;

Reflections after Sundance 2011

I've been absent from blogging for a couple months thanks to needing to help the clinical program where I teach prepare our accreditation application, so I'm resuming my regular blogging on the day after our annual summer ceremony. Enough has been written about the Sundance, that I don't need to dwell on the details. Rather, I want to write about what I learned this year and the implications I see for medicine and for those who don't participate in Sundance. Our Leader talked frequently about the Sundance being about love, as is the red road that we follow. Of course, people undertake the Sundance for many reasons, some being for healing of family members, and others for self-healing. As I settled into the dance, I thought of all the things I for which I could pray, and none quite fit. I wanted to pray for my son, who is 18 years old, and still figuring out his life, but I received the gentle message from the Tree (the center of the ceremony) that he was fine and all was in motion and had been worked out on many levels. None of the things I wanted seemed all that important in the context of the dance until I realized that the best I could do was to pray to increase my capacity to be helpful and healing to others. I also became more aware than ever before that so much of what we do in the dance is for the benefit of the people present, for their healing, to inspire them. Just as we use prayer and the power of spirit and the power of our own minds to transcend our limitations, we inspire those present and perhaps ill or suffering to take our example and to transcend theirs as well. Sundance is sacred drama in which all involved are lifted to higher levels of spiritual immersion. Within those levels, miracles can and do happen. One of my fellow dancers was a member of the Native American church aspiring to have his own fireplace -- what they call an altar. He told an amazing story about his wife's having been diagnosed with multiple, small tumors in the abdomen that were assumed to be malignant. While they waited for surgery, he and his fellow church members held a ceremony for her in their tradition. When he and his wife returned to the hospital for a follow-up CT scan to determine the best approach to remove the tumors, the physicians were amazed to see that all of them had disappeared. This is the power of ceremony and belief, the power of faith and mind. What does this mean for our mainstream world? One of my fellow Sundancers had learned that 378 dances take place each summer in the United States. Probably this is an underestimate since many dances are small family affairs that fall below the radar. Even if the average dance has 40 dancers (probably close to accurate, though some, like one in Rosebud, South Dakota, have as many as 200), the number of people is small compared to the population of the United States. Though the cultural practice is clearly being maintained and is growing with signs of persistence, relatively few will be called. What we can learn, however, is the power of faith, belief, and mind in healing and in health care. This power is realized through enactment. We have to do something. It's not often enough to sit quietly in one's room and wish to heal. We need others to participate in healing with us and we need people to witness our performance of wellness. There are other more common practices which can elicit these feelings, though probably not at the intensity of Sundance. They include drama therapy, other spiritual practices, and even the ritualistic practice of new behaviors. The context of the Brazilian healer, John of God, captures these elements, as well. People make pilgrimages to Brazil at great person effort, just as people sometimes drive hundreds of miles to get to a Sundance at great personal expense of time and money. People visiting John of God dress in white and line up for their audience, just as Sundancers wear red and line up. They believe that transformation will occur and it often does. They participate In a ceremonial healing that is witnessed by many others. They are told how to change their lives and often transcend their previous limitations to become able to do what they couldn't do before. We need more sacred drama in our lives. We need sacred drama sometimes to believe enough, to activate the power of mind, and, I would say (though others might say that I am speaking metaphorically), to engage the spirits and persuade them to help us. I've been speaking of sacred drama which means to me the ritualistic enactment of a spiritual story. Sundance is based around a cosmology in which the sun is the most powerful of all the Great Spirits, with the power to heal the people. Within this story, people play the roles of spirit beings. We spend four days purifying and when we enter the dance grounds, we enter into spirit world. Fasting and thirsting are ways to bring us closer to spirits who do not need food or water. My fellow dancer, Barbara, said, "It's both reaching to be spiritual and staying spiritually connected while suffering. It's about accepting life as is and refusing to be brought down by it." This is most evident on the fourth day when copious food and water will appear at the end of the dance, and being patient and waiting for the dance to conclude at its own speed and not at the desired pace of an ordinary person who's thirsty and hungry. Sundance is known among those who attend to be amazingly healing for veterans who are suffering the aftereffects of participation in war, and to allow them to return to productive, fulfilling lives. How does this happen? I realized that Sundance allows us to bodily enact the role of spiritual warrior, giving all the positive benefits of doing battle with none of the negatives. We form tight bonds with our comrades, our fellow dancers, in which we support each other to transcend our usual limits. We find love for people that are sometimes so different from us that we would never have bonded with them in any other context. We challenge ourselves physically through not drinking water or eating food for four days while sometimes dancing in harsh conditions of heat and humidity. Through the piercings, we are able to be wounded in ways that inspire pride and build self-esteem. Our bleeding becomes our badge of courage rather than a shameful wound. We return with medals in the form of the small scars that remain after the piercings. Any Sundancer can recognize another simply by noticing the scars on the chest, back, and arms. This opens participation in a community of warriors like none other. In this way, Sundance is far superior to the military because its mission is love and transformation, and the cultivation of kindness and compassion in a challenging context in which no one dies or is seriously wounded. For these same reasons, Sundance, and the red road which Sundancers follow, has become an alternative to gang membership by providing all the desirable elements to being in a gang with none of the negatives. No crimes need be committed for the dancer to experience that another has his or her back. There is that sense of working together to accomplish a common goal that is done individually and as a group effort. For me, I was blessed to achieve my commitments, but, had I not, my fellow dancers would have loved and accepted me for trying and for giving my all even if I didn't do what I set out to do. This is where Sundance shines over belonging to the military or to a gang. It is clearly a wholesome antidote for what people are lacking. Competitive sports have some of these same elements. The task requires preparation, both mental and physical. We strive to overcome our limitations. Pain is involved, or what my Buddhist friends call "voluntary suffering". They say that we grow and transform through choosing to suffer for the benefit of others and to find ourselves and a higher purpose and meaning in the midst of suffering. We are broken and become traumatized through involuntary suffering that is forced upon us against our will. Voluntary suffering prepares us in a way for those times when we must involuntarily suffer by teaching us the strength to maintain our sense of self and meaning and purpose in adverse conditions. After Sundance, I always want to pen some words to remind me of why I do this. Like many, I enter the dance grounds with some trepidations and fears that I must manage and overcome. I would say to myself reading this in 11 months from now to remember that spirit will pick you up and carry you the distance you need to go, that pain is transient and transformative, quickly over, leaving behind the sense of accomplishment for the good of others and of one's self, and that membership in this community of warriors is worth the pain and suffering involved. A fellow dancer who had come back from Iraq with what was being called post-traumatic stress disorder was afraid of being pierced. The last time, he had seen the dead from Iraq walking through the dance grounds and had fainted. I told him what I tell myself. "This is not like the pain of an enemy's wound. It's the pain of transmission of knowledge, of spiritual growth. Welcome it and think of it as an interesting, uplifting sensation, and not as pain. It's something you want, something for which you've asked, and not something that's being forced upon you." He liked this idea and said that it helped immensely. He went through the experience and felt that he had healed a huge part of his trauma. "No bodies in the arbor this time," he said. His sense of triumph will carry him through. Another dancer taught me an important lesson. In the previous year, he had believed it his duty to refuse support and medicine offered to mitigate his suffering fearing this would weaken his purpose and prayers. In doing this, he had barely made it through the dance. This year he told me that he had realized that when someone offers you a gift, it's for their benefit that you accept it; that part of the obligation of being in community is to let others help you even as you help them. He had learned that receiving compassion was not the same as quitting. He was able to accept medicine and support this year and had a much stronger dance. What helped me to transcend my limits was the encouragement and love of the helpers and my fellow dancers (including my partner). I tried harder and gave my all and more because they knew I could and wanted me to succeed. They encouraged me to do more than I thought I could. So, here's our challenge to become healthier as a society. Few will ever participate in a Sundance, but how can we use Sundance as a template to create opportunities for people to transcend and grow in the company and camaraderie of fellow seekers and helpers. The helpers in Sundance are personal and participatory as well. They share some of the suffering and have gone through many years of the dance as dancers before being called to help. They have been there and therefore have compassion for the new dancers. They know how to offer encouragement and give support in a Vygotskyian "zone of proximate development", in which their presence allows us to do things we couldn't do without them. I don't have a simple answer, but to say that we need more compassion and performative ceremony in health care. Health care practitioners would do better to act like the helpers in Sundance -- to convey the sense of having been there, too; to give support and encouragement that allows people to dip inside and find their inner resources as they undergo suffering in order to heal; to assist people to feel empowered and to develop a sense of agency and accomplishment; and to build community in which all feel equal and accepted, even when some have more experience and skills than others. We will do this through dialogue, through many voices talking in order to listen. The point of this essay is to start such a dialogue. And now, back to my desk job!

Sweat Lodge, Prayer, and Community

"Long long ago the Muscogee Creek people lived in a dark misty fog and they were cold. They felt along the walls of something damp and realized they were moving upwards. Slowly they emerged from the Earth and the fog blinded them. Unable to see and stricken with fear, the people and even the animals cried out until the wind blew away the fog so that they could see... In all four cardinal directions, the forces of fire confronted the people, and they had to make a decision. From the south, a yellow fire faced the people, a black fire burned in the West, a white fire was aflame in the East, but the people chose the red fire from the North. The fire of the North warmed the people and provided bright light over the world and enabled the plants to grow, so that the Muscogee Creeks learned to respect all of the elements for life".Should the people fail in their respect for nature and forget the ceremonials, the people would disappear from the land and it would fall beneath the waters of the ocean." Muscogee Creek traditional story, 1922, from Donald Fixico, p. 1-2 The American Indian Mind in a Linear World This weekend I had the opportunity to lead an inipi, or sweat lodge ceremony, for a group of health care providers from the American Institute for Medical Education's annual February Creativity and Madness conference, in Santa Fe, New Mexico. Given the subject matter of the conference, it's not surprising that more than half of these providers were in the mental health field. After three hours of preparation on Sunday afternoon following the formal closing of the conference, we convened on a bright, blue, sunny, but windy Presidents' Day morning in the mountains outside of Santa Fe, at the Heyokah Center, a facility started by our recently departed friend, Julie Rivers, who also founded a not-for-profit organization called Supporting Women Across Nations (SWAN -- Julie's mascot animal) over 30 years ago. SWAN and Heyokah continue thanks to Julie's sister, Donna. SWAN began to support indigenous women around the world to overcome gender-related oppression and to be encouraged to bring forth their own cultural healing traditions that women have carried for centuries, sometimes in secret when governments have been particularly suppressive. We were there on a similar mission -- to bring some of the wisdom of Native North American into the mainstream world of medicine and psychotherapy. We were there to remind our attendees (10 people from a conference of over 200) about the importance of keeping the ceremonials, as emphasized above by the story told by Fixico. The inipi, or sweat lodge ceremony has been well-described elsewhere, so I will be brief. I understand its primary purposes to be prayer and community building. Sweat lodges, with rare exceptions, provide a place and a context in which people pray. I was taught to "think globally, but pray locally." "Pray for things you can see come true in four days," was another teaching. I learned to pray that sick people still be with us and even feel a bit better by the upcoming Full Moon. In this way, we can see that prayers are answered and that awareness will build our faith so that progressively larger prayers can come true. The notion of prayer and the importance of community are two concepts which have largely disappeared from contemporary health care. Our goal in leading this ceremony was to show these practitioners that the values of prayer and community are important, and to experience how they can be built. The sweat lodge is a low dome-like structure, covered with sheets and blankets and canvas tarps (once upon a time, covered with animal skins). Bucko has described the many variations in just the Lakota Nations sweat lodges, but some basics persist, including heating rocks in a fire outside the lodge until they are sufficiently hot to bring into the lodge. Water is poured upon the rocks to generate steam, and the people sit inside on the earth around the rocks. Generally everywhere, four cycles of door closing to door opening exist. The cycles are often called rounds. At some point a sacred pipe is smoked to signify prayers being answered, people sing, and people pray. Ubiquitous is the sense of connectedness and belong that occurs through participation in the ceremony. I wrote in Coyote Medicine about the style of sweat lodge I learned to lead. It came through the Black Elk family lineage. In this style, we begin with a ritualistic filling of the pipe with tobacco after singing a traditional song. Ceremony prepares the pipe to do its job of translating our human prayers into a form that can travel straight to the Creator. Stones are brought into the lodge, sage is placed upon them, the first seven are placed in each direction and blessed by the pipe, the pipe is placed upon the altar, water is brought inside, the door is closed, and the round begins. Water is poured upon the stones to create steam and four songs are sung. This first round is for purification and release, dedicated to the West and the Sacred Beings who dwell there. The door opens, people rest a bit, more stones enter, the door closes, a song is sung, and each person gets an opportunity to pray. When we have gone around the circle and everyone has prayed, the door opens, medicine water is brought inside for people to drink, and the people rest again. Then, more stones enter, the door closes, four more songs are sung, and the door opens again. The second round is dedicated to the North and the beings who dwell there and the strength and endurance they bring us. The third round is dedicated to the East and to receiving vision, guidance, and direction. While the door is open between the third and fourth rounds, the pipe is brought inside for the most sacred part of the ceremony. It is smoked as it passes around the circle. During the last round stones are brought inside, the door is closed, a song is sung, and each person gets an opportunity to pray, sing, talk, or even tell a joke. This last round is more relaxed because the people have purified, prayed, been doctored by the medicine, received guidance and direction, and their prayers have been answered. Then the ceremony ends with a final song and the people leave. We conducted this ceremony. The people began as relative strangers. As each person prayed, the intimacy in the dark deepened. We felt each other's humanity. We shared each other's pain. We felt the common tragedies that underlie human life. By the fourth round, when people spoke again, the trust had deepened and more heart-felt prayers emerged, coupled with quiet testimonials to difficulties and tribulations, songs, and words of gratitude. After our feast, we concluded the day with a talking circle in which people shared their experience one after the other, clockwise. Uniformly at the end of the day, everyone recognized how important it was for people to have opportunities to be in ceremony together, to share their common humanity, to tell their difficult stories to an audience who cared, and to feel as if they belonged. This is what the inipi ceremony provides and what modern people so desperately need. Donald Fixico writes that "'Indian Thinking' is "seeing' things from a perspective emphasizing that circles and cycles are central to the world and that all things are related within the universe." This is what we are trying to teach experientially when we bring mainstream health care providers into the sweat lodge -- the power of circle and how to see our interconnectedness. Many traditional indigenous people experience this directly in their daily lives. Participation in the sweat lodge ceremony also teaches us about the indigenous experience of a metaphysical world. The ceremony creates an opportunity to participate in that metaphysical world. Contemporary health care has eliminated the metaphysical completely in favor of empirical evidence. Ceremony allows us to see the connection between two or entities or beings, some of which are non-physical, and to see how ourselves in relationship to these entities and all others. Fixico (p. 3) says, "This holistic perception is the indigenous ethos of American Indians and how they understand their environment, the world, and the universe." Native Americans who are knowledgeable of their culture see things in more than just a human-to human context or from within the constraints of materialism. The sweat lodge is an educational laboratory in which anyone can learn this way of perceiving the world. Participation in this world view is healing in and of itself, meaning that it leads toward a greater sense of wholeness, connectedness, and belonging. Sometimes, this greater sense of harmony and balance leads to greater physical health, sometimes not, but the opposite seems much more often true, that isolation, alienation, fragmentation, and disharmony, lead to illness. Achieving belonging and community is an antidote for so many of our modern ails -- stress disorders, back pain, arthritis, and more. Bringing people together brings our bodies back together. Within the circles of humanity, we need counselors and storytellers who encourage us to tell our own stories, who provide a role model for others to believe that things can be different. We all originate from nations of storytellers and all of our houses were houses of prayer.

Adolescent Addictions and Las Vegas

This weekend I attended an adolescent addictions and mental health conference in Las Vegas, Nevada, which, of course, seems the perfect place to discuss addictions. The conference was sponsored by U.S. Journal Trainings, a group with which I enjoy working. My talk was about narrative psychotherapy. I began by sharing some of what we learned in Australia -- that the world's indigenous peoples are the trunk of the tree of narrative practices, their traditions extended downward into ancient roots of ancestral wisdom from deep within the earth to connect upon which they live. Their practices arise from the bones of all of our collective ancestors, as well as the bones of the animals and the plants. Our contemporary work in narrative practices represents branches outward from that tree. As is typical for many of my audiences, a handful of people had read one book on narrative psychotherapy and it had been Michael White. As I mentioned in my blogs from Australia, Michael White certainly represents one branch on the narrative tree, but there are many others. However, I did learn from my colleague at Union, Bill Lax, that Michael White did acknowledge the central role and contributions of Australia's aboriginal people to his thought and techniques. I had not seen that in the one Michael White book that I read, and Bill is looking for the citations. However, my point to the audience was that narrative practice is not synonymous with Michael White, who was one rather skillful narrative practitioner, but not the field's only theoretician. Narrative practice began over 43,000 years ago, I said, when people were recognizably telling sophisticated stories for the purpose of changing each other's perspective. This was the point at which long distance trade began and was linked to a series of volcanic eruptions that covered the earth in vog, blocking out sunlight, changing the climate, and forcing people to venture far from home. In many respects, we discovered Others in an entirely more dramatic way during this time. This is when story became even more important than it already was. I dipped into neuroscience -- to Marcus Raichle's (Washington University, St. Louis) studies showing that making up story is the default mode of the brain and burns the least glucose, especially compared to more difficult activities like mindfulness meditation. I reminded people of the obvious -- that when we don't direct our minds purposefully to a topic, we find ourselves "daydreaming" of social situations -- encounters with bosses, arguments with family members, upcoming situations in which we will find ourselves. We run "what if" simulations" imagining ourselves behaving in a variety of ways, while we observe how our imaginary others will respond. These social situation simulations form the basis for our plotting our social maneuvers to get what we want. In folk psychology terms, we can talk about beliefs and desires. We want to be held in high esteem by our boss, our spouse, our children, so we construct internal representations of these characters and run simulations to predict the best behaviors to achieve our goals. We believe that we should have what we want and we believe that our representations of these characters from our outer world are sufficiently close as to allow us to predict their behavior. We have "theory" of these other people's minds. Theories are just stories that tell us what other people are likely to do in particular situations. I have a collection of stories about what my boss has done in a variety of situations and I extract information and form future stories about what he is most likely to do in a hypothetical situation. We need our big brains to do this, because running social simulations and keeping track of all this information on other people requires much computational time. Brian Boyd, a professor at the University of Auckland, believes that our brains evolved exactly for this purpose -- social survival, since biological survival among our species is predicated upon social survival. Then I told the audience about Schank and Abelson. None of them knew these scientists from Yale University and Northwestern University. I described how these two believe that no human knowledge exists that is not storied. All facts, all information, all experience is stored in the form of a story about how to use those facts and when they were used and who used them and for what purpose. We humans do not waste brain space on facts that have no obvious use (Rainman, of, course, being an exception). I challenged people to imagine a fact that could be called into memory without a story about how it is useful and a time that it was used and for what reason should I continue to remember this fact. One person in an audience of about 400 people claimed to be able to imagine such a fact. The rest were with me. Therefore, I said, anything uniquely human is part of a narrative structure. Narrative structures incorporate a flow of time. There is a sequencing that involves befores and afters. They have characters who move about in a location. They have plot. The convey meaning and purpose. They are colored by emotion. They are plausible to an audience who find them engaging and entertaining -- worthy of paying attention. Then we turned our attention to the stories surrounding adolescence -- to the negotiation of an identity. During this socially constructed part of life that we call adolescence, the stories that saturate modern culture prescribe a crisis of identity in which the adolescent "finds" him- or her true self and discovers his or her unique talents -- what he or she is destined to do when grown up. This story didn't exist in 1491, I said, in North America, because everyone knew what to do when grown up. One's life was prescribed through stories about how people lived and what they did. The number of choices was limited. With the explosion of choice for how to live and what to do came stories about adolescent identity crises, mid-life crises, and the crisis of making meaning at the end of one's life. These activities were not necessary in North America in 1491. The same stories saturated everyone and dictated how to think and act. Adolescents, I said, are trying out stories to see what they like the best, what works best for them to get what they want (which is not always certain), and what feels the most uniquely satisfying. We know some of these characters that the can copy -- the gangbanger, the pothead, the jock, the cheerleader, the good student, the shop crowd, emu, and more. The list continues for as many variations in identity as we can find. Adolescents try on some of these stories the way they might try different clothes at the mall. They watch the reactions of important others for feedback about their performance of these roles/stories. Criticism by parents might reinforce the value of the role. Criticism by peers might make one rethink the desirability of a role in exchange for trying another or modifying that one. The story that saturates modern culture, I remarked, is the story of the magic potion. It's everywhere we go in the form of the water from the Fountain of Youth, the holy water of Lourdes, the sacred dirt of Sactuario de Chimayo in New Mexico, ayahausco, and the pharmaceutical aids on television. Our modern culture is in search of fast ways to get what we want. We want drugs to keep us up all night. We want drugs to put us to sleep after being up all night. How can we not get seduced into believing in magic potions? Here is our challenge -- to create alternatives to the magic potion story. To find a way to make the slower approaches to growth and development sexy! We do this in the Native American world through the sun dance, through the vision quest, through the sweat lodge, and through other ceremonies. We try to captivate the youth with the drama of positive questing. We need heroic stories that counteract the magic potion story. That's our challenge in working with youth substance misuse -- to make it more exciting not to use, than to use! www.mehl-madrona.com