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.

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

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

Undoing the Mechanical: Narrative Medicine

Continuing my thread, about the mechanical, there are some ways to undo this story and replace it with another story.  I began with the simple question, "How long have you had this pain?"


Answer: "Low grade all my life, but severe for the past three years

Me: "What does the pain interfere with your doing?

Answer: "Everything I love to do: swim, weed, take care of chickens, walk the dog, be out on the land…"

We need a new story to support before we do a ceremony to ask for a change. Ellders have consistently explained to me that most of the work happens before the ceremony, which happens last.  Ceremony is meant to be what Malcolm Gladwell calls the tipping point, the last snowfall before the avalanche.  Before doing ceremony, we need to line up those ducks in a row (a long line of dominos makes another great metaphor) so that one touch change everything. One breath of spirit of spirit is sufficient.

I have seen healing elders go to someone’s house for a week, talking to everyone and engaging in a story changing process so when the ceremony came, everyone was already in line to expect a major shift. We need more richness to the story in order to change it.

So, I ask, "three years ago did something changein your life? I start in the western perspective of the medicine wheel with "did anything traumatic happen to your body?" She answered No.The northern perspective would be about change in community relationships? No. The eastern perspective is about change in spiritual relationships. She answered, no. The southern perspective is about changes in relationship and family.  She said, "Around that time I started resenting my husand because he wanted me to do things I didn’t want to do."  Now we are getting somewhere!  More later....

Our tendency to make everything mechanical

I wanted to dialogue with anyone who's reading about our tendency to make our health entirely mechanical. We certainly have the capacity to invent amazing stories, so why don't we use some of our imagination to wonder why things like back pain could be more than just mechanical.

I was speaking this week to a woman with neck pain.  We discussed her orthopedic surgeon's ordering repeat X-rays every three months.  She didn't know that the research literature shows no correlation of X-ray findings with pain.  "Why would he order so many X-rays?" she wondered.

"He's looking for something he can treat." I answered.  "He's not actually treating you; he's treating your X-ray.  If it's bad enough, he can justify surgery in the hopes that it will make you better."

I told her about Dr. Sarno in New York City and his book on back pain. He is an orthopedic surgeon who wrote a book about back pain rarely being mechanical and much more often being related to how we live.  He helps people resolve their back pain with a process that looks very much like cognitive behavioral therapy.

My friend hadn't heard about him either. I suggested she see him the next time she was in New York since I suspected he would have more impact than a mere friend (his office is fancier, his furniture more designer; probably hangs his diplomas framed on the wall).  Eighty percent of his patients improved with CBT and many fewer with surgery.  I suggested to my friend that surgery could make her better, worse, or no different. I told her about the arthroscopic surgery study that was reported in the New York Times in which sham surgery (an incision only) was equal to arthroscopic knee surgery in outcome one year afterwards (all patients improved dramatically).  She remembered reading that story.


I asked her, "What do you tell yourself about your pain?"

WOMAN: I hace a twisted cervical spine. It happened at birth. I started dancing too young. I’m just getting old."

This answer implies that the issue is purely physical. Native healers can’t conceive this way. The body is not separately mechanically from evertyhing else.I iremember my friend who was asked how would you treat arthritis? I don’t know – I don’t know her bring her to see me!

Ursula in Coyote Healing and how do people become sick?

Ursula raises the larger question of how does physical illness come about. I think illness emerges as either a consequence or an epiphenomenon of the embodied enactment of stories. All thoughts have physiological consequences just as I mentioned for imagination. Medical students who watch horror movies show decreases in immune function just as medical students who wtach comedies show increases in immune function. We can't explain the mechanism by which that happens, but we know that it does. So, your emotional experience, which is a direct result of your perception of the world, which arises from the stories you hold about the world and enact in the world, affects your physiology. The story of guilt and self-blame and self-loathing is probably a bummer for the average white blood cell who's more interesting in responding vigorously to happiness and joy. Our emotions, however, arise from our position in a social world and the stories in which we grow up. It's the flip side of the competition story. For every winnter, there are 100 (or more) losers. What's it like to be the winner or the loser? I think Taleb (in the Black Swan) and Gladwell (in Outliers) both make the excellent point that after you put in your 10,000 hours to become an expert (Doidge uses that number also), it's largely luck and social capital, not talent or genius. Yet, the more we believe the individual genius story, and the more we're not the big winner, the more we beat ourselves up. The more we beat ourselves up, the more beaten down we feel. Up, down. Up , down. It weighs heavy on a body, and is probably in service to capitalism because the more down we feel, the more stuff we buy and services we consume.