Day 10 of the Australian Journey

Today was day of reflection and the day that we travel to Sydney for that part of our cross-cultural exchange.   Before the flight, we spent the morning caucusing and planning for the next year.   We learned that funding exists for next year and that a camp will happen, which pleased and excited us.   My highpoint from camp was Lily, the woman healer/elder/leader from Millumgimby in the Northern Territories, crying during the men's choir concert.   On the last evening of every camp, the men's choir comes over by boat to eat dinner with us and sing to us.   The choir is led by a Maori man, James, who I described in my blog last year.   Briefly, James is a Maori nuclear physicist who has worked for years for the Australian defense industry and has run Maori-style sweat lodges in Australian prisons for Maori inmates ( and anyone else who wanted to come).   The choir is composed of, as they say, "black fellows and white fellows."   After dinner the choir serenaded us with Maori songs, a song from the Solomon Islands, from where one of its members hailed, aboriginal songs, and English language favorites (West Virginia, Oh Shenandoah, and the like).   Lily cried because she had never believed in her life time that white men would sing to her.   I thought this moment got to the heart of what we are trying to accomplish with cultural exchange -- for all the Voices to speak and be heard with equal volume and respect; to equalize the privileged voices and the dispossessed voices.   Lily's tears were evidence to me that we were accomplishing our mission.

I wrote last year about the "black-white" distinction in Australia.   It rings strange to my eyes.   When I look at aboriginal people here, I do not see black people.   I see Australian aboriginal people.   So when they call themselves black fellows and talk about the white fellows, it's strangely disconcerting to me.   It reminds of how people talked in the American South during my childhood which was deeply disturbing at the time.   I confess to thinking of "black" people as people who identify with ancestors who came from Africa to North America against their will.   Of course, they don't all look black either.   In fact, an actually black person is very hard to find.   Most people are varying shades of brown depending upon how much melanin they have in their skin.   The colder the climate, the less melanin you need.   The more sun, the more you need.   The downside to having lots of melanin is that it slows the absorption of some of the vitamin D in climates with little sun.   A theory exists that African-Americans have more depression than white Americans (controlling for poverty, etc.) because of a relative lack of vitamin D.   I know when I measure vitamin D in Vermont, it's always low.   I stopped measuring it and just give everyone vitamin D, because that's more cost effective, since it can't hurt you anyway and it's cheap.   Maybe if I practiced in Arizona, I'd rethink that position.   But, anyway, it's confusing to see people calling themselves black fellows, but I've come to understand it's a result of the colonizing position that the British took as they invaded the Australian continent and forcibly imposed their will upon the people who lived here.   I suspect it justified their actions because, in the 19^th century, "black" fellows were seen as inferior to "white" fellows -- primitive, just one step above the animals.   Of course, "red" fellows in the United States (why red, I do not know) were even seen as below "black" fellows.   All this was justified with a variety of pseudoscience, including phrenology, the study of the shape of skulls and what that revealed about intelligence.   Charles Darwin, to his credit, argued vigorously that skin color was a minor gene that had very little relation to anything else and almost no correlation with anything except the strength of the sun where one's ancestors evolved.

Part of the success of our project is echoed in the increasing number of requests we are receiving to come to other communities and to assist other communities in creating "culture camps".   Apparently this idea of spending one week together exchanging culture and participating in each other's ceremonies is novel.   In Canada, culture camps to celebrate one's own culture and heritage are common.   In North America, now, many people spend over one week together to celebrate the sun dance.   But apparently spending time together to exchange culture is new.   We have seen that the process results in increased awareness of the value of one's own culture and culture carriers (elders, leaders, etc.).   There appears to be a beneficial effect of watching someone from another culture share his or her practices and participating in them.   The process brings us closer to together.   In celebrating diversity, we find unity.   We have seen that culture camp has inspired some of the "white fellows" to look for their own ancestors and practices, whatever those are.  

We also heard that being able to tell one's stories -- personal and cultural -- to others and to feel heard by them was also important.   For aboriginal people to tell their personal and cultural stories to "white folks" and for the "white folks" to listen was powerful.   Whenever trauma occurs, all the stories must be told and culture camp provides an opportunity for this to happen.   The energy of the story is what happens between storyteller and listener when the story is told.   This energy produces healing.   The obstacles in the story are the gifts of the story.   In the myths and legends of a people, our personal stories can emerge without the complication of interpretation which suppresses the story and the healing.   We heard that non-indigenous cultures always want the newest, shiniest, most dramatic stories, while indigenous cultures like the old stories, the ones that have been told over and over.

A woman in our group told about working in Croatia soon after the war.   She was hired to help women tell stories to their children, but the women had lost all the stories of their culture and only had Disney stories.   She was puzzled about what to do.   She went to a house one freezing morning when it snowed, and sat with the young mother around her kitchen table, who said, "It's bad for us, but not as bad as it is for the lions."   This family had little food and was virtually malnourished but they were most concerned for the lions in the zoo who were suffering more than they.   Our friend told about walking through the snow and entering the zoo in the middle of winter and how heart-wrenching it was to see the desperately thin, starving animals.   She came upon the fence around the lions and thought that once upon a time, this must have been nice, in a Communist sort of way.   She switched her task to working with the local women to create a new story about saving the lions and finding a way to get them out of the zoo and to a place where they could thrive.

Then we flew to Sydney and were met by Pauline, who will be our hostess for the next three days.   We drove through incredibly thick rush hour traffic to her home in Manly and had a marvelous meal of cioppino, prepared by her husband who had lived in San Francisco.

Day 9 of the Australian Journey

I awoke to run only to be greeted by the sound of a driving rain.   Though I don't relish the thought of loading the boats while getting drenched, the sound of the rain on the roof is strangely comforting.   The temperature is chilly.   We were warned that summer is very hot in southeastern Australia, even up to 40 degrees.   I am sitting on the veranda under the sheltered portion wearing a shirt, a sweat shirt, and a jacket.   I almost didn't bring the jacket.

Today is our last day at Boole Poole.   We travel again today to the cultural center for further interactions with the community and the elders.   We had an extra day at Boole Poole last year and that allowed us to do "doctoring" for some of the elders who came over on the boat.   I wrote about that in last year's blogs which are still available at www.futurehealth.org.     By doctoring, I mean the aboriginal North American version of energy medicine/osteopathy.   I suspect that every culture had its own form of energy medicine and hands-own manipulative medicine, though some do not carry these practices in their current repertoire.

                Eventually enough people awoke that we could have a discussion on the veranda around breakfast while the rain continued to steadily fall.   Our breakfast question was how to bring spirituality into human services.   That led us to consider pathology as an organizer.   In medicine and psychology, what's wrong with you, the diagnostic category, has become the pivot point around which everything is organized.   The assumption is that diagnosis tells you everything you need to know to assist someone.   Then relationship comes not to matter because once the diagnosis is made, anyone can apply the treatment.   Spirituality becomes unimportant.   It is like the steam generated by a locomotive -- pretty to much but not necessary for the operation of the engine.   It is a byproduct that can be ignored.   How do we change that?

                Our conclusion was that we have to listen to the many stories surrounding the person and to grant validity to all those stories.   Everyone has a story about how and why they got sick.   Often their stories have fused with the stories of the dominant paradigm, such as "I'm sick because I got bad genes and there's nothing I can do about it."   Everyone also has a story about how healing is supposed to happen.   We have stories that guide us to what to expect when we consult someone who is supposed to help us.   My story in seeking a traditional healer is very different from my story in consulting an orthopedic surgeon.   I have different expectations for what they will do to me and for me.   But, what if I had an expectation that each of them should see the Divine in me and acknowledge it before proceeding with what they do?   That seems logical for the traditional healer, but why can't I also expect that from the orthopedic surgeon?   Thus, the human services toward which we are striving includes a willingness to meet people where they are and to experience their experience.   As a practitioner in a human service, I need to be willing to "be in the story" that's brought to me.   I need to "be in the details".   I cannot maintain the same level of clinical distance characteristic of the biomedical paradigm.   I actually have to be empathic.   I actually have to care even if I can't do more than that.   Caring and listening are powerful interventions even if nothing else can be done.

                This led us to discuss the indoctrination that new professionals receive. Their training and socialization makes them less able to interact with aboriginal people.   Some people enjoy formality and distance.   Most aboriginal patients do not -- at least not in the same way.   I know I want to feel heard.   I want to believe that someone cares enough about me to hear all the stories that I feel I need to tell.   Perhaps he or she will care enough to elicit some stories from me that I didn't know I had.   I need to enter into the stories of my clients enough to share some lived space ("Lebenswelt") with them.   That is considered unprofessional in some circles.   I am not saying I need to share my ongoing problems with them, though I do use stories about problems I have solved as teaching tales with clients.   I think we distance ourselves from clients related to our fear of ambiguity, mystery, and helplessness.   The biomedical model purports to give us a certainty that it doesn't deliver.   However, if we scrunch our eyes tightly shut, we can pretend that all is as it says it is and that we have certainty.   Sometimes we are helpless to do anything and we don't like that either.   We are afraid to not know the answer.   If I can maintain enough distance, I won't be affected by the vicissitudes of my clients' lives, including when they die.   In the biomedical model, I can't afford to care too much.   I can't afford to love my patients.

                Doctors and patients often come from radically different cultures.   Implicit within this is a difference in class and wealth.   Managed care in the United States has removed much of the wealth possibility from doctors, but the image remains.   In other countries, doctors never had the wealth potential that they had in the capitalist countries.   When we come from different cultures, we may have such stereotyped stories about each other that we are incapable of listening or interacting.   We interact as if both of us were wearing a mask.   Maybe we are!

                We agreed that our shared task, and what culture camp accomplishes, is to build bridges with others who are trying to see the world and human services differently.   Our current systems do not encourage emotions for and with the clients.   We want to change that and to experience the human condition with them and from them.   When we do that, we bring spirituality into our practice because that is one aspect of being human -- to reach out to what is greater than us, to contemplate larger powers, to appreciate our small stature in the universe and to be awed by the vastness of all we can perceive.

                Culture camp is giving us a shared language for how to move in this direction.   It is validating our experience of wanting to hear each other's' stories.   By observing each other working in our own context, we learn to more deeply appreciate the human stories and to see the richness of our own.   Seeing others' cultures helps us to find our own hidden assumptions, the beliefs and stories generating those beliefs that we don't know we have. We have trouble seeing the stories which surrounded us when we were born as stories.   We think of them as ineluctable facts.   Seeing others who don't share those most basic stories helps us to recognize our own.

                One of the aboriginal elders told us that those who have lost sight of the world as animated and magical need to practice seeing the artifacts and sacred objects as really alive.   They need to learn to see the energy around the object instead of the object itself.   Compassion is the ears getting bigger and bigger, she said.   "Call upon your ancestors," she said, "and hear everything without judging."   We talked about the difference between judgment and discernment.   I can discern that I don't want to be involved in a particular process or don't want it for myself, without being critical of those who are involved in that process.   We heard about the young men from Idaho who come to the Northern Territories to convert the locals to the Church of Latter Day Saints.   They are on a mission.   They look so out of place in the tropics wearing white shirts and ties.   They must always be home at 10pm.   "I don't want their religion or to do what they're doing," one man said, "but I don't judge them for doing it.   Being in this strange new place must be quite exciting for a sheltered young person from the rural United States."  

                I brought up my favorite Lakota concept of the nagi, which I have already discussed in these blogs.   Unique about this concept is the sense of person as swarm and the notion of swaminess, which is a mathematical/engineering concept now of how swarms behave.    We are swarms of conscious stories and tellers of those stories rather than concrete objects.    Where all the bees gather, there is a queen.   The queen represents the collection of concatenated stories that we privilege as better somehow than the rest.   My example of swarm behavior comes from deer nibbling on the leaves of acacia trees.   The acacia trees then secrete toxins to stop the deer from nibbling which every acacia tree in the neighborhood does simultaneously.

                A woman present brought our attention to how are bodies speak their story for us.   Laura told a story about a time when she felt traumatized.   She was also suffering from pain from her left shoulder down to her left hip.   She used phrases like, "I'm all twisted up about this."   "I overreached."   "I stretched myself too far." "I feel down."   "I bent over backwards."   We were able to point out to her how her language matched her body sensations.   The situations of her life were reflected or were parallel in her body.

                The discussions continued throughout the day with the eventual result of planning for next year's conference.   The rain continued so we made our soaking way to the boat with all of the sweat lodge blankets, some of which got quite wet.   We made a bumpy trip to the mainland and loaded the car for the drive back to Melbourne.

Day 6 of the Australian Journey 2012

Today we arrived at Boole Poole, the ancestral land and burial grounds owned by the aboriginal cooperative for the formal start of Culture Camp 2012.   Several of us were wearing Culture Camp 2011 T-shirts in bold red, black, and yellow, the colors of the Australian aboriginal flag.   Boole Poole is only accessible by boat which was a rough ride in a rainy sea.   Flocks of pelicans sailed overhead, experts at riding the currents of wind.   Black swans floated gracefully on the swells, while young cormorants appeared to be walking on water as they got out of the way of the boat, flapping their wings faster than imaginable.   The rain had begun as we unloaded the boat at the pier.   By the time we had pulled the trolley with our things to the house, it was a downpour.

The food at Boole Poole is continuous and one meal runs into the next.   Looking for an alternative to eating, I decided to interview Miriam, the newest physician to work for the Aboriginal Cooperative and their first and only full-time physicians.   My colleague, Rocky, had already spent time with her on his last journey to Australia when he consulted to the physicians who worked for the Cooperative.    The rain drummed on the roof as we talked in the living room of the house while most everyone else watched films of aboriginal dancing from the community at Mullingimby, the home of Shadow and Lily.

"How long have you been at the Coop now?" I asked.

"Since last August, 2011.   Now, it's six months."   Miriam answered.    She had trained in Brazil and had practiced for some time with aboriginal people there.   In Brazil she had a catchment area of 4000 people.   She worked for the public medical care system.   In her clinic, she had four health workers, one nurse, and her.   I wondered how it was to have that many families under your care.   She said it was a matter of doing the match.   In any given month, one expects 4% acute care visits.   She used the morbidity tables for the percentages of chronic diseases in her practice to calculate how much time to allocate for chronic disease care.   Time was very scientifically managed.   Next I asked her what was her biggest challenge in coming to the Coop in her first week.

"My first week was one of introductions and cultural awareness.   I was taken to the different sites I needed to know about; taken to meet the people with whom I would be working and whom I would be calling. They (the coop) introduced me to elders.   That first week was also an introduction for the community to me.   It was a pleasure.   They believed it was fundamental for me to understand the geographical space in which the patients lived.   They were open to all my questions.   They introduced me to all the places that were important to know.   The two aboriginal health workers did that -- Shane and Judi Ann.   Judi worked with the midwife and could bring her all the issues with pregnancies in young people and what they need, their expectations.   That was my first week." I was impressed with how culturally sensitive the Coop was to Miriam.   I hoped we had contributed something to that awareness. Then I asked Miriam about her second week.

"During my second week I was in the unit of my mentor, Dr. Jane Greason.   She was able to introduce me to the program and what they had been doing in the community.   She has been there more than 12 years."   Then I asked her what other doctors work for the Coop.

"Dr. Greason is my supervisor.   There is Dr. Gene Wofurt who was raised in Bairnsdale, then Dr. Schoefeld, and Dr. Black.   We have two offices at the health center.   Usually only one session or two sessions occur at the same time."   I learned that the other doctors had contracts with the Coop and did their own billings.   Miriam was on a salary.

"My challenge is, not by the production, but to help people get well.   I am not billing medicare like the other doctors who have to see patients one after the other, 1, 2, 3, 4.   I have A, B, and C consultations.   An A consultation is scheduled for 10 to 15 minutes.   B is 40 minutes and C is one hour.   Because we have the other doctors, if I have another doctor at the unit, the other doctor does their patients and I do the health assessments with the aboriginal health worker and do the gp planning."   I hadn't heard the term "gp planning" so I asked what that was.   Assessments are always category C consultations.

"After the assessment, you have at least some idea of the risk factors, medications, and social information.   That supports the gp planning.   We identify the patients with the chronic disease and the special needs.   After that, you have to work in a way that you agree with the patients and negotiate with them what can be done and how.   We set some goals between us.   I have to write this down.   That is the product we call GP planning.   The Coop is a very special situation because they have more than just general practice.   They have the family service, the alcohol and drugs follow-up, the midwifery service, and many more community outreach services.   With these special services, it's easier for us to go further than a simple gp plan in mainstream medicine.   There they have hard work because they don't have the facilities to refer as I have here.

"When I arrived in the heatlh center, I realized some of the aboriginal health workers were not having time with the doctors.   Every doctor had a small time with the patient.   I started doing the health assessments with the aboriginal health worker and the patient together.   I also did the gp planning with the patient and the aboriginal health worker together.   This seemed like a natural way to do this. It would be a longer appointment if we did it together, but we would get so much more done.   It is the job of the aboriginal health worker to visit the patient in the community and to make sure the plan that we have negotiating is being implemented.   If I cannot finish the gp planning with the patient, I will finish it with the aboriginal health worker.   Sometimes that's necessary because I didn't have all the necessary background.

"We have a clinic coordinator who is a nurse practitioner and we have Leslie who is a nurse practitioner who is more responsible for immunizations and wound management.   She's a more unit centered nurse.   Another nurse does diabetic education.   We have another midwife who works with Liz Boyer, who is one of the doctors responsible for antenatal care and deliveries at the hospital.   The midwife is a nurse, too.

"After gp planning, I keep in contact with the aboriginal health worker to be sure every action that we have planned is happening.   In that stage I had some concerns because the aboriginal health workers belong to the families.   If I have a male patient, they have male business and they will be ok with these patients, but if they belong to other families, maybe they will not be ok.   We lost one aboriginal health worker because she couldn't do the male business.   Judi worked with the midwife and had good support in the women's business.   It's very hard because you know they belong to their families and sometimes they don't want to get involved in other families' business.   I have to be very careful, because I don't know where I am walking.   Some of them are close to these patients.   I have to be very respectful.   Once I went to aboriginal health worker and said what I wanted to do with this patient and he said, doctor, I prefer not to work with this patient, because she is my wife.   He could help her as a husband but not as a health worker.

"Patient confidentiality is minimal.   Everybody is a relative.   You have to be very careful what you have as a goal.   What we have to do is ask the patient.   I have the opportunity to talk with the patient myself before we discuss things with the aboriginal health worker.   I explain what is a good aboriginal health worker and they agree with me.   Then I ask them if they are ok with who will be assigned to them.   Some of them don't accept the aboriginal health worker."   I asked Miriam about the challenges to health in the community.

"People in the community want to be heard.   They have a hard time with drug addiction, alcohol, domestic violence, but when you open the door, they go through it.   If you listen to them, they will tell you things which will give them some relief.   I remember one patient who was very upset.   In their community, it's not normal practice to have an elder in a retirement home.   She was very upset with that.   She came for high blood pressure.   She was very upset.   She was fighting with the family because one of the sisters got the guardianship of their mother.   The sister wanted their mom in this specific retirement home.   I started to treat her blood pressure but I knew the stressful situation was    part of what was raising her blood pressure. Part of my job was to be a problem solver strategist.   To help her make small changes to cope with the situation was what I needed to do.   She is still working through her issues but she is changing.   She asked me to support her with her alcohol issue because that was why her mother was in the retirement home.   She was not able to take care of her mother because of her drinking.   She was then able to go to alcohol treatment.   She could choose an alcohol counselor. " I have this problem and how can I solve with the resources we have here.'   Now her mom is in the retirement home and she is struggling to cope with alcohol problems and she accepted the situation as transitory because she wants to recover so she can take care of her mother.   She is in the middle of her process now.   She has access to the consultations.   Every time she needs to contact me, I have an agenda for her to come every week as a crisis like, trying to support her in this journey.  

"Second I have a list of resources we can present to the patient.   Patients can choose what they want.   If it's housing, I have people who can help with that. One of her [the above patient] issues was that she didn't have a house.   She got connected to the aboriginal legal services and I could do a letter supporting her for housing.   It was important for her for the crazy stress.  

"The aboriginal health worker is very important, because they know how to work the system.   If the patient doesn't allow me to contact the aboriginal health worker, I have the list of the resources and I ask the patient how to help them.   Sometimes they say it's impossible.   They give me the limitations.

Day 5 of the Australian Journey 2012

Today is our second day in Warburton with Auntie Jennie and the Karith House of Prayer.   Every morning on the Australian Tour, I get up before the sun and run.   Yesterday I ran along the Upper Yarra River to Martyr Hill (a 27% grade) where I painstakingly ascended to the top, then entered the Donna Buang Trail, a 70 kilometer hike, of which I sampled just the first bit. The songs of the birds spectacularly surrounded me, resembling what I would expect from a rain forest, though in my naivete, I expected monkeys to be part of the auditory scenery.   I had the privilege to see a beautiful red fox, which surprised me since I didn't think foxes lived in Australia.   Later when I asked about the fox, I learned that they had been brought to Australia by the British rulers for their classic fox hunt.   The foxes quickly overran the local wildlife since they had no natural predators and became pests.   (Just like the English, someone at the breakfast table quipped.)   I pointed out that it wasn't actually the fault of the foxes, since they weren't the ones to buy the tickets to Australia and probably didn't enjoy the journey either.   You can get $10 for killing a fox and presenting its pelt.   It's equally not the personal fault of those who have English ancestry for bringing the foxes since they weren't alive when the fox idea was conceived and executed.   I don't think we have to hold guilt for the deeds of our ancestors.   There's enough in the world to make everyone dysfunctional without needing more.   I agree with don Miguel Ruiz and Olivier Clerc that we need to forgive and be forgiven more than we need to blame and be blamed.

This part of Australia superficially resembles Vermont, where I live.   The mountains are a bit higher in Vermont, but that's where the resemblance ends.   There's no rocks here.   The forest floor is thickly filled with ferns and exotic looking plants that resemble large pineapple plants without   the fruit.   The major tree is the eucalyptus or gum.   As one ascends to the higher altitudes, pines appear, but not like any Vermont pine.   Last year we were running when it was still dark and saw a wombat.   I only saw scat this year.   Surprisingly given daylight savings time, the sun rises late in Southeastern Australia.

This morning I took a different route.   I ran up a new road on the same steep hill to get to the O'Shaunessy Aqueduct Trail.   I ran along an old aqueduct for a ways before turning up the hill on the Mt. Victoria Trail.   I wondered how one keeps the water out of the aqueduct even as streams tumbled down the hill beneath it.   Nature was breaking up the concrete and taking back the land.   A short ways up the last trail, I had to turn around and ran back to Karith.   I can vouch that it's quicker to run downhill than uphill but it's harder on the thighs.

Warburton is a small town, barely one row of buildings on either side of the road.   The architecture is one I have only encountered in Australia, a kind of combination between English country homes and Indonesian style.   The closest I have seen elsewhere is the French Quarter in New Orleans.   The Upper Yarra River runs behind one of those rows, flowing all the way to Melbourne and into the ocean there.   I met a woman named Maya who wrote a marvelous book on her hiking journey along the Upper Yarra River from its source to the sea.   I asked her if she was going to honor any other rivers, but she said, "No, this is my homeland.   That is my River.   I wouldn't have authority or permission to write about anyone else's river.   She was obviously aboriginal in her thinking about land and territory.

When we arrived at the Village Hall where we were doing the workshop, the door was locked.   We milled around in front of the movie posters including George Clooney's latest film for the Town Hall doubled as the Village Cinema.   Since "the show must go on", we had to improvise.   Our hosts were frantically trying to track down one of the City employees to open the building.   I suggested we go sit beside the river and at least get started.   We meandered down our side of the river to the Brisbane Bridge and crossed over to the other side where I had spotted a nice grassy area suitable for our group.   Rocky and I proceeded to do the opening song to honor the Four Directions after we had acknowledged the land, the aboriginal people who were attached to this land along with their ancestors, and the spirits who walked upon the land.   Then we did a spirit calling song to make sure that proper notice had been given to the spirits that we were planning to do a ceremony.   Auntie Jennie then spoke some about the importance of men coming into the medicine.   In her family as in mine, there were at least two, if not three, generations which were entirely lacking in men.   All the men were dead or in jail or lost.   My grandfather was the only exception as was Aunt Jennie's.   She continued to talk about the men in her family and her ancestors which inspired me to propose that we do a tobacco ceremony in which we smoke for the spirits and anyone who receives a message from them stands up and delivers it.   This turned out to be a powerful ceremony.   I offered the tobacco and a number of people stood and spoke in Quaker meeting fashion.   In my mind's eye I saw my ancestors crossing the great divide (the Pacific Ocean) and embracing Auntie Jennie's ancestors and all sitting down in a circle and smoking together to signify unity and peacefulness.   One said that war actually hadn't been on the planet all that long and could still be eradicated.   I saw ancestors standing behind each person present.   Several others spoke of similar sightings.   We passed tobacco around the circle for everyone to smoke just as I had seen.   Then one of our hosts appeared and announced that the employee who was supposed to open the hall had finally arrived and we could return.   Many of us did not want to leave the river and its soothing sounds as it moved past the first rocks I had seen in this countryside.

After we settled back into the building, Rocky spoke about the untold and silent stories that become physical illnesses.   These stories need to be elicited.   The organs and the tissues who manifest the diseases need to be engaged in conversation to tell their stories.   The lessons we were learning were not just pertinent to mental health.   He gave an example of working with a woman who was having severe right hip pain.   He used acupuncture and some osteopathy while he encouraged her to let her hip tell its story.   As a surprising but highly relevant story emerged, the pain moved to the left hip, then the left knee, and then left her body.   It had been stuck in her hip.   I suggested Brian Broom's marvelous book, Meaning-full Illness.   Auntie Jennie confirmed that this view was also consistent with what aboriginal people believe and how they heal in her area of Australia.

After lunch we wanted people to experience how ceremony builds community, so we chose a ceremony that I created based upon my readings from ethnographies written before 1900 of a "Welcome to Camp" ceremony.   It hasn't been done since 1880, as far as I can determine.   I can imagine someone getting ready to bristle, so I'll quickly say that I believe it's acceptable to create ceremony for specific purposes as the need arises.   It's not a Native American ceremony because it's not currently done and there's no model to follow or elder to teach it.   It may have some Native American flavor (we can't help infusing our spirituality into the ceremonies we create), but it's really an ecumenical attempt at experiencing some degree of transcendence toward the spiritual, which is exactly what I would call it.   Or, since I'm also a member of the Unitarian-Universalist Church, perhaps I should call it a "U-U greeting ceremony".

   The inspiration for this ceremony comes from Plains peoples of North America, before they were penned into reservations.   In those days, camps frequently moved.   During certain times of the year camps would join each other for celebrations and larger rituals.   A ceremony was done to oversee this process.   In one that I read, seven tipis were set in each of the seven directions so that the person walked a spiral toward the center.   This was done outside and to the East of the main camp.   Those people wanting admission to camp participated in the ceremony along with those who controlled the admissions process.   The supplicant who wished to enter the camp started in the West and passed to each of the directions.   In the original ceremony, the intent was that each person proved that he possessed the virtue of that direction.   In my readings, only men participated, but that may have been a side effect of the gender-nearsightedness of many of the ethnographers writing before 1880 who were often sexist and might not have noticed women even if they outnumbered men.   At each direction, the applicant to the camp tells a story about a deed that exemplifies the virtues of that direction.   In my ceremony, I used courage for the west, strength and endurance for the north, receiving and following a vision for the east, compassion for the south, protecting someone for the sky, and nurturing someone for the earth.   Then he is welcomed in the center and led into camp.   I'm going to guess no one was ever turned away because the incoming group were known and had been previously vetted.   This was just a formal way to say hello.

I use my ceremony with Native American people though, as I said, it is not a traditional Native American ceremony.   I use it especially with people who have drug and alcohol problems because they are not used to saying anything positive about themselves.   The beauty of this ceremony is that it emphasizes one's good traits and deeds.   So many people are quick to tell stories about their faults and misdeeds, but isn't it much harder to tell stories about what we have done well, or times when we have been courageous, or strong, or compassionate, or protected someone or something else?   This ceremony forces people to reflect upon what is good about them and to share it with another person who only listens, standing in the position that symbolically represents one of the Directions.   Participants feel how it changes them to tell good stories instead of bad stories and they feel the camaraderie that comes from being heard without commentary or personal response and being accepted.   Those who have completed the process are led to a nearby part of the room where they can sing, dance, or help each other in some way.   We keep a continual steam of singing and dancing going, because, as a Sari elder told us in Mexico, you can never sing or dance enough for the spirits.   When we did ceremony with her, she would exhort us with "mas bailando; mas cantando".

We did this ceremony with the group and Auntie Jennie agreed that it did succeed in giving them some flavor of the transcendence and sense of group membership that participation in tradition ceremony in community provides.   People also spoke about how difficult it was at first to be positive about oneself and how embarrassed they were.   Isn't it interesting that we are more embarrassed to tell positive stories about ourselves than negative ones?!   They also spoke about how transformative it felt to actually get out the positive story and for it to be accepted. They described the joy of completing the process and being welcomed to the community.   For some that community will continue, since talking circles are held weekly for those who live in the area and efforts are being made to find constructive ways for people to spend time with each other.

Later that evening after the workshop, we talked with our hosts about the problem in aboriginal communities for some people that family gathering was centered around drinking or doing drugs. The physician in our party who worked in the aboriginal community reported that she wasn't permitted by some families to make home visits on Thursday, Friday, or Saturday because of the partying that they didn't want her to see.     In relation to this we talked about the power of ceremony, even the ceremony of drinking together, for it is, after all, a kind of eucharist or communion.   It's no accident that alcohol is called "spirits".   We talked about the necessity of engaging the elders to put healthier ceremonies back into place in communities in such a way that people can notice and can attend.

In Warburton, we finished the day by offering traditional pipe ceremonies for those present.   We left to return to Melbourne to prepare to travel into the East Gippsland countryside early the next morning for Culture Camp 2012.

Day 4 of the Australian Journey 2012: Musings with Auntie Jennie

Today we are in Warburton where we encounter Auntie Jennie, an aboriginal elder from Queensland.   I wrote about Auntie Jennie last year.   She is doing her medicine for her community and much the same way as aboriginal elders in North America.   Our revelation from last year was that we are more similar than different and that continues to be true.   We stayed at Karith, a Catholic retreat center for people of all faiths.   Karith means a place for prayer, and this is what it is, managed by Sister Catherine and Brother Ken.  

We began our workshop/worship in Warburton by singing and calling in the spirits of the land and its original people.   Then we did an introduction process in which each person says what they are called, where they come from, and introduces one of their ancestors to the other person in one quick sentence or so.    I learned that sentences are not quick in Australia and people have much to say and tell.   Introductions took over two hours.   People were starved for the opportunity to tell their stories and to be heard.   After lunch we continued with the theme of hearing the silenced voices, one that is apropos to Australia in which aboriginal people were silenced to ourselves in which we silence the voices within that we don't like or don't appreciate.   In the post-lunch exercise, much as what we did in the Hearing Voices conference, the goal was to meet one or more of our voices that we have silenced and to remove the gag and allow them to talk and be heard.   This turned out to be powerful, too.   So many of our voices have been silenced by the dominant culture, which is one of greed and individuality.   The voices of sustainability and cooperation have been drowned out by the sounds of greed and what Thomas King, the Canadian aboriginal writer, has called the "Ferenghi laws of acquisition (see his collection of stories called A Short History of Indians in Canada".   The Ferenghi are from Star Trek and primarily represent the "all for me, and none for you" point of view.   Allowing the silenced voices to speak is a powerful process.

I went on to talk about the ways in which the mind is a model of the larger social world.   Just as we have marginalized indigenous people in the broader social world, we have marginalized the indigenous voices within us in the social world of our minds.   We need to allow them to be heard.   Here comes dialogical self theory again, which was the topic of my keynote address at the Hearing Voices conference.   Dialogical self theory sees the mind as a collection of voices all of which are speaking at once trying to be heard.   Therapy consists of imposing a kind of order of politeness and respect in which all the voices can be heard and can dialogue with each other.   Richter (author of integraring Existentialism and Narrative Therapy) has written about the many me's within us.   Each "me" manages one of my relationships and carries voices, experiences, and stories for negotiating that relationship.   Some "me's" are more appropriate for some contexts than others.   Social skill consists of knowing which me's to bring out for any given encounter.  

Relevant to this is Marius Romme, Professor of Social Psychiatry at the University of Limburg in Maastricht, The Netherlands, who is credited as being one of the European founders of the Hearing Voices movement, though in my talks, I was quick to add that what Romme proposed has been practiced and believed by aboriginal elders for centuries, perhaps even 43,000 years.   Romme was practicing psychiatry in The Netherlands when one of his patients, Patsy Haagan, said "You believe in a God no one can see, so why don't you believe in the voices which I at least can definitely hear and which are real to me."    Romme thought about her proposition and found that he could agree with it.   Why not?    He accepted the ontological reality of Patsy's voices (just as indigenous elders do). He invited other voice hearers to talk together about their experiences but found that although they could talk they didn't really help each other.    So, he and Patsy appeared on Dutch TV and invited others who heard voices to call into the program.   Four hundred, fifty viewers who heard voices phoned.   Of these, 150 people said they coped without the assistance of psychiatry; indeed some said they were happy to hear voices.   Romme asked, "Could perhaps the techniques used by those who coped well with the voices be used by those who didn't?"   A conference was organized to encourage broader discussion, similar to the conference we had in Melbourne.   From this Healing Voices groups formed around the world.   Ron Coleman, who spoke at the Conference, founded the first one in England 25 years ago.

My proposition was that narrative medicine has much to offer the Hearing Voices movement just as does dialogical self theory and therapy.   Rita Charon, MD, PhD, one of the leaders in the world narrative medicine movement wrote that narrative medicine is "Medicine practiced with narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others." (Charon R. Welcome and introduction. Presented at: Narrative Medicine: a colloquium; May 2, 2003; Columbia University, New York, NY). As doctors/, we act on the narratives presented to us daily by patients, their families, and other health care team members.   This is what Romme did.   He accepted the story brought to him by Patsy Haagan and worked within that story.   The late Canadian family physician, Miriam Divinsky wrote that, "[Stories] help us see other ways of doing things that might free us from self-reproach or shame". Hearing and telling stories is comforting and bonds people together."   This is what people had found at the Hearing Voices conference and what we found at the Warburton workshop.   Coming together in circle to tell and hear our stories with each other creates relief and builds community.   Within the Lakota concept of nagi, once we hear another's stories they are forever a part of us.

In Warburton, I spoke about the nagi, which is the swarm surrounding us of all the stories that have ever been told about us, by us, and by those who have influenced us coupled with a part of the spirit of the teller of that story.   Nagi is what forms and shapes us and makes us who and what we are.   It is our legacy.   Once we tell or hear a story that story becomes forever a part of the listeners nagi.   Miriam Divinsky further wrote that "Stories offer insight, understanding, and new perspectives".They educate us and they feed our imaginations." (Divinsky M. Stories for life. Introduction to narrative medicine. Can Fam Physician 2007;53:203-5 (Eng), 209-11 (Fr))      Through story

(1) we structure and interpret our life experiences;

(2) we create a coherent life story;

(3) we construct, display and reinforce our sense of self;

(4) and we manage this self in relation to others in our social worlds.

As I said in Melbourne, story is the default mode of our brains.   It is our best way to store and manage information.   The narrative structure is ubiquitous in human experience and emerges, according to the Scottish developmental psychologist, Colwyn Trevarthan, even in the early exchanges between mother and infant.   In these interactions, infants engage in stories without words or with words supplied by their mothers.   We have the task of creating a coherent life story, often with the help of our family and friends.   Through the use of narrative structures, we invent an "I" to integrate our many me's.   In fact, we know at least one part of the brain located in the mesial pre-frontal cortex which eliminates our ability to tell a coherent "I" story if it is rendered dysfunction by stroke or other damage.   We use story to run countless simulations about what might happen if we behaved in particular ways in future encounters with others.   I gave an example of this in which I asked everyone to remember a time in which he or she had an argument with their spouse or partner and had to leave home for work or another errand before the argument was resolved.   "All the way home," I said, "you are running various "what if"." scenarios in your mind, rehearsing the discussion that will take place when you arrive home.   Depending upon the outcomes of these various simulations, you decide whether to stop for Chinese take-out, flowers, chocolates, or perhaps a drink at the pub."   Everyone could relate to this.

                Then I defined a narrative unit (following the work of Labov) as one containing at least 2 Complicating Action clauses where the verbs are in the past or historic present tense, and where we can infer an order to the clauses.   There are also one or more Orientation clauses setting out who was involved in the events, when and where the events took place, and giving other necessary background information.   I used an example of a short narrative from one of our clients who comes to our complicated minds group.   Mandy said,   "Then there was the time when I killed my boyfriend, except that he didn't die, and there he was at my back, trying to strangle me again."   This actually has three Action clauses.   True to the requirement for an Orientation clause (which can be implicit in the conversation), Mandy added, "That was when we lived in Georgia and I was dealing coke and he was really jealous, but then we broke up and now we're best friends. I know all his girlfriends and all his kids."   I asked everyone if they could feel Mandy's charm as a person from the story and everyone could.   This occurs because we recognize the other aspect of a narrative -- the affective strand of meaning where narrators reveal their feelings about the events they are accounting.   This justifies the telling and shows the kind of person the speaker claims to be: "narrative is a presentation of the self, and the evaluative component in particular establishes the kind of self that is presented".   This illustrates the narrative competence of the speaker in putting together a multi-voice, multi-faceted story in accessible language.   

Next I moved onto illnesses, discussing how narrative competence allows us to Use the different perspectives of storytelling to create a complete picture of the illness and its meaning to the patient.

The narrative of an illness needs to not only give the patient a voice, but also to re-present the dialogue between patient and caregivers, inclusive of the voice of the caregiver or health professional.   I gave the example of the story of the first encounter with the illness being named.   Mandy said, Linda: We fought for 6 hours that day because I fought back.   At one point I was slamming his head into my knee.   I went to the hospital and that's when I found out I was pregnant. That"s when they diagnosed me."   To her credit, Mandy had received every psychiatric diagnosis available from someone.   This is how she came to have a "complicated mind".    Mandy also told habitual stories that illustrate usual activities.   For example, she said, " I get so angry, I mean he would wake me up for no reason, and he knows I can never get to sleep and so I have a 3 hour panic attack because he needs $5, right now, so I would lock him in the basement.   I would just get so sad. I would take all my pills, whatever I had around. I'd still do it but my son put me right, he said he didn't want to be without me. They would call me from the other side, my best friend, my son's father. And he was really good looking."   Mandy was talking about her usual activity of taking all the pills at hand when she was upset.   She was however, entertaining a counter story during her time she had been in the Complicated Minds group -- that her son loved her and would miss her and needed her to stop overdosing on pills.   People also have "reported speech" narratives in which they describe important conversations with others.   Mandy said, "The doctors don't want to hear what I tell them.   They get really nervous when I come in the office. I made one of them brownies but it doesn't help."   Mandy's experiences with physicians were generally negative.   She made them uncomfortable and recognized it.   These stories are important.   During our interactions with health professions decisions are made about the management of the illness and the health practitioners story about the illness is transmitted to the patient. Interactions between patients and health care professionals thus play a major role in the social construction of illness narratives.   We rely upon physicians to tell us what we have and why we have it.   This generates "because narratives" in which we explain ourselves, often in reference and comparison to others, which are called narratives of comparison with others.

                We completed the workshop in Warburton with examples and exercises of people telling each other stories and listening for the smaller narrative units comprising the story, thereby recognizing points of potential intervention.   Then we went across the street to the Polish Jester for a wonderful Polish meal of pickled vegetables, smoked herring, and stuffed cabbage.   I fell asleep immediately upon returning to Karith.

Culture as Medicine Day2 for 2012: Hearing Voices

Today I gave the keynote address at the International Healing Voices Conference in Melbourne.   The conference was organized by Voices Vic (for Victoria, the state in which Melbourne lies).   Speakers came from around the world -- Ron Coleman (who started the Hearing Voices Network in the U.K.); a woman from Auckland, New Zealand; Eleanor, a young woman/psychologist/voice hearer from Australia, and more.   Unlike most mental health conference, where the attendees are mostly practitioners of various kinds, this conference was mostly "patients".   And was it different!   The energy was so upbeat!   The conference was all about hope and recovery.   People told inspiring story after story of being severely mentally ill and recovering to the point of becoming a practicing psychologist, for example.   I'll start with Eleanor's story.

By all appearances Eleanor was an aspiring young psychologist.   She could have help her own at any professional meeting.   She was attractive, articulate, well-dressed, well-spoken -- the kind of graduate any psychology program would be proud to proclaim.   However, once upon a time, she had been a patient in the mental health system.   She heard voices that tortured her.   Once she tried to drill a hole in her head to let the voice out.   She wasn't trying to harm herself.   She just really believed that the voice would leave if it had an exit pathway.   Her longest hospitalization had been for 5 months and she had more of them than she could count or remember.   She had connected with the Hearing Voices Movement and had learned how to manage her voices.   Slowly but surely the positive voices gained sway over the negative voices.   Eventually her mind became more peaceful and she was able to return to her University studies.   She could concentrate and learn again and went on to complete a doctorate in clinical psychology and to become a licensed psychologist.

As so many people have told me, Eleanor reported that the medications only made her worse.   The drugs didn't touch the voices.   They just made her completely unable to think.   Being unable to think prevented her from doing the cognitive therapy she needed to do to learn how to manage the voices.   Being unable to think left her in complete misery.   Eleanor told us that she wasn't against medication or anything that helped people.   She would have been happy to take a drug that worked.   However, she said, "I'm against forcing people to take drugs that don't work and make them worse and prevent them from working through the problem."   For that she received a standing ovation from the audience.   I was impressed.   This was not an anti-psychiatry group.   This was a group of pro-active consumers demanding realism of outcome.   They were angry with a mental health system which pretended to help when it didn't and actually made them worse.

However, I have gone ahead of myself.   The conference began with a welcome from its organizer, a woman named Indigo, who also heard voices.   Then the "Welcome to Country" was given by an aboriginal man from the people who originally inhabited the area that is now known as Melbourne.   He played an amazing concert on a digeridoo that he had made.   Then, to my surprise, a North American aboriginal man came out to dance.   He was Ojibway from Minnesota.   The music started and to my surprise it was a Lakota song.   He didn't dance.   He waited and waited.   Then he looked at Indigo puzzled.   "You put on the wrong song," he said.   He went to the podium and clicked the correct song on the computer.   Ojibway words filled the room instead of the Lakota.   I had known that song and was singing along.   However, I knew Ojibway wouldn't dance necessarily to Lakota.   That's been a rivalry for hundreds of years.   In 1420, the Lakota attempted to defeat the Ojibway in the area around Thunder Bay, Ontario.   The Lakota suffered a miserable defeat.   I'm reminded of that every time I visit Thunder Bay.

Next came the official welcome and address from the Chair of the Agency funding Voices Vic, which was delivered by a man named Quinn from Prahan Mission.   To my surprise, our host, Tony Gee, had worked with Quinn in the past at other agencies.   Tony is the Chair of Life Is ". Foundation, which is one of the collaborators in our Australian Cross Cultural Exchange.   Life Is" has a mission of preventing suicide and assisting those left behind by a suicide to heal.   Then came my talk.   I'm going to share what I had to say, but first more observations from the conference.

The strong indigenous presence also contributed to making this a different kind of conference than others I have attended.   We heard often that aboriginal healers were not afraid of voices.   Hearing voices is normal and honored in the aboriginal community.   One hears the voices of the ancestors, the voices of spirits, the voices of the animals and of nature.   To be a voice hearer is a privilege and an honor.   Aboriginal elders were present from diverse parts of Australia to share how they assisted people who heard frightening and terrifying voices.

All this converged on the subject of my talk -- that hearing voices is an ordinary human experience that we all have.   What's different is the spin we put on the voices and the voices to which we give our attention.   I showed brain imaging slides for "hearing voices", "people with the diagnosis of schizophrenia who were not at the moment hearing voices, and so called "normal controls".   I joked with the audience about not knowing where they could have found a room full of normal people, since they were so rare.   The imaging studies suggested that the only difference was in the frontal lobes.   The frontal lobes are what we use to make up stories about our voices.   One story is that these are just our own thoughts.   Then we call those people with intrusive and disturbing thoughts "OCD".   We spare them the psychosis diagnosis because they know the thoughts are their own despite their disturbing and even terrifying nature.   In other stories, the Voices are Ascended Masters trying to take over one's mind for the purpose of eternal punishment.   In the indigenous story, some of these voices are the whispters of the ancestors, some of them come from the spirits, and one's job is to listen carefully to all the voices and practice discernment.   An elder told us never do anything a voice tells you to do if it will hurt you or someone else.   Good spirits wouldn't tell you to hurt anyone or hurt yourself.   They're funny and they make you feel good.   My suggestion is that hearing voices isn't abnormal and isn't even worthy of treatment or diagnosis.   Instead, people suffer due to the stories they create or absorb about what the voices mean and who they are and also for being fixated on negative voices that criticize, castigate, berate, wheedle, and excoriate their listener. I suggested that this tendency to focus on the negative voices is related to painful life experiences which was in keeping with Eleanor's talk (came after mine) in which she reported that people who experience trauma are 46 times more likely to receive a psychotic diagnosis than those who don't.   Eleanor's trauma was being raped and molested repetitively in a day care center run by pedophiles.   She told us her home life otherwise was atraumatic and that her parents had been loving and warm, but she had had no way to express her traumatic experiences since they occurred when she was so young and they just kept building inside of her like a pressure cooker ready to explode which she finally did during her second year at college.

I suggested that the work with voices was to make sure all voices are heard and none are necessarily more privileged than others even when those inner voices match the broader messages of the dominant culture.   I introduced Bakhtin, Hermans, and dialogical self theory to the group.   The Russian, Mikhail Bakhtin, is easily one of my favorite philosophers.   In one often quoted passage, he described the mind as a room filled with a cacophony of polyphonous voices, each arguing with the other, each trying to achieve ascendency, some forming shifting coalitions to win out over others (sounds like the U.S. Congress to me!).   He thought Doestoevsky had done the best job describing the mind in this manner, especially in Crime and Punishment, in the way in which Raskolnikov's mind is presented.

Hermans and his colleagues have taken this further into a mature psychological theory which matches the concepts of social constructionism and critical constructivism.   The mind consists of many "me's".   Each "me" emerges to manage a particular relationship and collection of stories related to that relationship.     More about this tomorrow!

Medical Writing: The Healing Power of Narrative

Today begins my 2012 journey to Australia for Culture Camp with the Gippsland and East Gippsland Aboriginal Cooperative. We continue our mission to assist them to incorporate more of their culture and heritage into their health care. Particularly, we hope to midwife a process of their discovering their own ways instead of just grafting onto their world the practices of the people from the Northern Territories who never lost their ceremonies and their language. However, Gippsland and East Gippsland are very different from the North. They are the farthest Southeast tip of Australia. Only the island of Tasmania lies any further East. They are a lake, ocean, and woodland people from a temperate climate where snow occurs in the winter in the high mountains. They are not people of the tropics. Their culture and language (Gunnai/Kernai) is different from those of the Northern Territories. Through a convergence of our delegation of Native Americans and of those from the Northern Territories and of those from Gippsland and East Gippsland, perhaps something magical will occur. Changes have occurred in our party. My colleague, Rocky Crocker, is still coming. He is a family physician who teaches in the Center for Integrative Medicine at the University of Arizona -- Andy Weil's program. He is also the President of our Board for the Coyote Institute for Studies of Change and Transformation, based in Brattleboro, Vermont. Rocky is Choctaw from Mississippi and talks like a real Southern gentleman. We were also going to bring two Lakota colleagues from South Dakota, but the woman had to have surgery and also couldn't come. Barbara Mainguy, however, could not come. She has come each year for the past three years. We are high over the Western New Mexico desert in a United Airlines flight from Albuquerque to Los Angeles. So Rocky and I will carry on for everyone. Beneath us are clouds and desert. No snow. The land is arid and dry -- so opposite of our home in Vermont. Melbourne will be in the height of summer, like the latter half of July in the United States. I've never been there in summer but I'm told that temperatures can top 40 degrees, though still not as hot as Tucson. My hottest day ever was +53 degrees one summer in Phoenix where we fried eggs on the car hood just because we could and mercifully spent most of the day in the swimming pool. I can't even remember why I was there anymore, but I was. We are coming from the Creativity and Madness Conference in Santa Fe, New Mexico. My talk was physician writers: the healing power of Narrative. Besides a marvelous Saturday night dinner, we spent most of our time preparing this talk. Our only other activities consisted of lunch with our friend Marga and her daughter. Marga is an amazing fitness expert and filmmaker who is currently unemployed thanks to the vicissitudes and foibles of St. Vincent Hospital in Santa Fe. She had been working there as a patient's complaints manager, but most of her department was "retired". I wondered with her who the hospital would get to talk the angry patients out of suing, since that had been her primary task. We wondered if the malpractice insurance premiums were perhaps less expensive than the salaries of people to prevent malpractice actions. We didn't know. We saw our friend, Amy Stein, who does a marvelous workshop for physicians and other health practitioners on how to draw a self-portrait. Amy has published a paper on her work in the Permanente Journal, a medical publication. It can be accessed at no charge by typing into google's search engine, "Amy Stein Permanente Journal self-portrait". In a beautiful place like Santa Fe, it's important to remind them that other places have beauty, also. We began with a quote from the physician, Anton Chekov, who said, "'Medicine is my lawful wife; literature is my mistress.'' I quipped to the audience, by the time we're done, "I hope you'll agree that Chekov should have said, as Dr. Tom Janisse (Editor of The Permanente Journal) said, "Medicine is storytelling; storytelling is medicine." Writing about our patients brings out the huge amount that is left unsaid in the encounter between physician and patient and physician and world. Writing allows us to be more than a clinical voice. It not only humanizes the patient, but also the physician. Current availability of media and access to ways of creating text is a revolution in medicine, allowing us now to write our clinical histories (stories) with our patients and allowing patients to edit and re-write those stories so that a rich, life-capturing document can emerge from the clinical encounter. Writing also allows us to manage the difficulties of medical practice. Writing the case story gives us more perspectives and awareness than we had before. Helping the patient to write his/her story reveals details and clarity never present before. It is also therapeutic (aka healing) for the person telling the story. I mentioned a 1999 study in the Journal of the American Medical Association in which writing about traumatic experiences helped people to make additional improvement over optimal medical management for both asthma and rheumatoid arthritis. For these people, storytelling is medicine. Engaging in this storying process also facilitates a more ethical and socially just relationship with patients because of the equalization of power that it entails and the respect the hearing people's stories creates. Then I made a humorous "black box warning" like the FDA does for drugs. James Gates Percival, an early 19th-century physician poet from Connecticut wrote: "If pleasure meet my ever-weeping eye, I see a demon lurking 'neath its flow'rs; The smile of joy but wakes the heavy sigh, And seems as sad as when the tempest low'rs" Diane Cox of the New York Times wrote that "Dr. Percival spent most of his life rejecting medicine for writing, then rejecting writing for medicine, all interspersed with nervous breakdowns and suicide attempts." So apparently writing doesn't work for everyone, though we could make the counter-argument that perhaps Dr. Percival would have succeeded at suicide had he not had poetry as an outlet. It's all in how you see the road: as leading to the bleak, horrors of winter, or toward the joys of another season's passage. Writing helps us get clear on that. Then I offered a poem by Mary Dowd, MD, from The Permanente Journal, Fall 2008. 12 (4): The door clangs shut. All eyes turn toward the diversion. The nurse and I walk in, two little female sticks, bobbing in a sea of men. Refresh Tag(s): Aboriginal; Culture; Healing; Language; Medicine; Poetry; Story; StoryTelling; StoryTelling; Suffering; (more...) Add to My Group(s) February 23, 2012 at 12:35:46 View Ratings | Rate It Promoted to Headline (H3) on 2/23/12: Permalink Medical Writing: the Healing Power of Narrative Add this Page to Facebook! Submit to Twitter Submit to Reddit Submit to Stumble Upon Tell A Friend Become a Fan SAVE AS FAVORITE VIEW FAVORITES Get Embed HTML Code By Lewis Mehl-Madrona (about the author) Become a Fan Become a Fan (22 fans) -- Page 2 of 5 page(s) futurehealth.org The room is large, but small, dimly lit, swarming with elbows, feet, faces dozens of men in orange scrubs talking, joking shoving, pushing pacing, roaming. The ceiling is high, but low, from two tiers up it presses down on me, filled with a gray-brown cloud, invisible, of something nameless, edgy, hostile and immeasurably sad. I feel the stares of men looking, and not looking at me wanting contact, conversation, attention, sympathy, distraction, anything, anything at all Wanting, so much wanting I feel it pressing in squeezing me bruising me like thumbprints, collapsing me. I shut down all my doors and windows and focus on a spot across the room Refresh Tag(s): Aboriginal; Culture; Healing; Language; Medicine; Poetry; Story; StoryTelling; StoryTelling; Suffering; (more...) Add to My Group(s) February 23, 2012 at 12:35:46 View Ratings | Rate It Promoted to Headline (H3) on 2/23/12: Permalink Medical Writing: the Healing Power of Narrative Add this Page to Facebook! Submit to Twitter Submit to Reddit Submit to Stumble Upon Tell A Friend Become a Fan SAVE AS FAVORITE VIEW FAVORITES Get Embed HTML Code By Lewis Mehl-Madrona (about the author) Become a Fan Become a Fan (22 fans) -- Page 4 of 5 page(s) futurehealth.org where a thin bar of sunlight filters through barbed wire to light a concrete court. I met Mary at a narrative medicine day for a literary arts conference at Goddard College. She works as a physician for the Department of Corrections in Maine. Her beautiful poem represents how physicians use poetry to make sense and meaning of difficult experiences. Then we looked at Kimberly Myers and Michael J. Green's paper from the Annals of Internal Medicine. January 18, 2011 (vol. 154 no. 2 129-130). They wrote how telling (and listening to) stories has long been held to have a positive effect on health. Narrative medicine studies suggest that telling others about one's illness can help ease suffering, by imposing a narrative order on frightening events. This was by way of introducing a paper by Thomas Houston and colleagues from the University of Massachusetts Medical School which was entitled "Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial (same journal, pp. 77-84). They studied 230 African Americans with hypertension in an inner-city safety-net clinic in the southern United States. They provided people with 3 DVDs that contained patient stories about how people got their blood pressure under control, told by people who were very much like the patients who were watching the DVD's. The outcomes were changes in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months. Most patients (71.4%) were women, and the mean age was 53.7 years. Among patients with baseline uncontrolled hypertension, watching stories statistically significantly reduced blood pressures. Patients with already controlled hypertension at baseline did not change over time between study groups. So writing and storytelling matters! Then I used the example of Oliver Sachs, best-selling author, physician, and professor of neurology and psychiatry at the Columbia University Medical Center. In 2007, he was named the first Columbia University Artist, in recognition of his contributions to the arts. He is best known for his collections of neurological case histories, including The Man who Mistook his Wife for a Hat (1985), Musicophilia: Tales of Music and the Brain (2007) and The Mind's Eye (2010). Awakenings (1973), his book about a group of patients who had survived the great encephalitis lethargica epidemic of the early twentieth century, inspired the 1990 Academy Award-nominated feature film starring Robert De Niro and Robin Williams. The New York Times has referred to him as "the poet laureate of medicine." Sachs is an example of turning case histories into literature and reveals much about how writing and literature can help us understand human suffering. Here's a short quote from The Man who Mistook his Wife for a Hat, which is an example of cortical blindness, in which a man "sees" without actually knowing that he sees. His optical system works and his brain works with it, but he has lost awareness of it because of a stroke. "And yet there was something a bit odd. He faced me as he spoke, was oriented towards me, and yet there was something the matter -- it was difficult to formulate. He faced me with his ears, I came to think, but not with his eyes. These, instead of looking, gazing, at me, "taking me in', in the normal way, made sudden strange fixations -- on my nose, on my right ear, down to my chin, up to my right eye -- as if noting (even studying) these individual features, but not seeing my whole face, its changing expressions, "me', as a whole. -- p. 9 ""Can I help?' I asked. "Help what? Help whom?' "Help you put on your shoe.' "Ach,' he said, "I had forgotten the shoe,' adding, sotto voce, "The shoe? The shoe?' He seemed baffled. "Your shoe,' I repeated. "Perhaps you'd put it on.' He continued to look downwards, thought not at the shoe, with an intense but misplaced concentration. Finally his gaze settled on his foot: "That is my shoe, yes?' "Did I mishear? Did he mis-see? "My eyes,' he explained, and put a hand to his foot. "This is my shoe, no?' "No, it is not. That is your foot. There is your shoe.' "Ah! I thought that was my foot.' Was he joking? Was he mad? Was he blind?" This passage gives us such a wonderful sense of what it's like to sit with someone who looks like they can see but can't actually see. The man eventually puts his hand on his wife's hair thinking it's his hat and tries to lift up her hair to put it on his head, which is how the story gets its name. On March 10th and 11th, I'll be in the Woodstock, NY area for a two day weekend workshop on narrative approaches to creating community through ceremony. On April 29th, I do a one week event at Kripalu Center for Health and Healing which involves Cherokee bodywork and ceremony and ritual. The details are on their website at www.kripalu.org.