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.

On the Nature of Afflictions

"The affliction is the doorway; it is not the thing itself. The afflicted one is being asked to make an offering for the community." Thus, began Deena Metzger this past Saturday in a workshop which I co-facilitated with her in Topanga Canyon, California. Deena is a writer, a novelist and essayist, perhaps best known for her personal and inspirational writing about her own breast cancer experience. We sat together with a room full of people on top of a mountain next to the largest "inside city limits" park in the world, the Topanga Canyon Preserve which lies entirely within the city of Los Angeles. Coyotes intermittently howled their agreements and disagreements with our discourse from close quarters inside the canyon. Large ground squirrels (as large as our Vermont woodchucks) scampered from boulder to boulder outside the window. The vast expanse of Los Angeles lay nearby but out of sight from this panoramic vista. Within contemporary medicine and psychology, we have invented "things" to have. We have bipolar. We have attention deficit. We have PTSD. People want to know what they have. Rarely do the come to the consultation room acknowledging that they have been invited to enter a doorway to explore the nature of the universe. Yesterday I sat in my office with a woman who "had" leukemia. She had come to the understanding that she had never permitted herself the indulgence of exploring her own life until she was diagnosed with leukemia. Then she had something sufficiently serious as to justify her adventures into inner space. As her leukemia improved (co-incident with her inner journey), she wondered if she would reach a time when the severity of her condition no longer justified the indulgence of exploring the world of her mind and relationships to others. "So," I said, "in order for us to continue our work, will your leukemia have to relapse?" That comment shocked an awareness in her that she could continue for the sheer joy of exploring without the excuse of having a potentially life-threatening illness. Leukemia had invited her to open a door, but she could remain in the dimensions of the mind long after the invitation had expired. In 1976, Deena wrote that "cancer is silence". She was describing women who went "crazy", had nervous breakdowns, got heavily drugged, and then got cancer. She was determined to speak whatever had been silenced in her. Of course, I don't think cancer is always silence, but I do think cancer, as well as other illnesses, emerge interactively as meaning-making opportunities for those who have them. The meaning of the illness can sometimes be transformed into the meaning of the healing. Deena was describing an experiential phenomenon of her time -- the silencing of wild and crazy women through drugs and the emergence of that energy in other ways. She reminded me of the insanity of the changes in our small brook that happened during Hurricane Irene. So much water fell from the sky that nothing could contain it. Dams burst. The rise in water level was measured in meters. We can appreciate that still when we see refrigerators wrapped around the top of trees or car hoods nestled in branches far too high to reach. Deena believed that telling her story would be healing. For her, and for a generation of women, it was. The radical departure of this brand of narrative medicine from the biomedical model lies in the awareness of the embeddedness of illness in the entire context of a life story, even if the affliction is a mysterious visitor, even if it remains silent and cannot be made to speak. However shrouded in mystery it remains, it is a being with ontological validity. Within the medical model, illness is isolated, fragmented, and silenced. Its existence is denied. Its presence as a being is avoided. I believe illness has a story to tell. Visitor, friend, enemy, obstacle, antagonist, helper, or villain -- whatever it may be (and it can be all simultaneously), our affliction stands before us ready for discourse, no longer silent. The transition from positivist to narrative medicine gives illness back its voice and is fundamentally reanimating to the world. In medieval times, illness spoke. Ingmar Bergman's famous movie, The Seventh Seal, reveals the voice of the Black Plague in the being of Death itself who plays chess with the knight, returning from the crusades, expecting to lose, but with the intent of saving the lives of others with whom he is traveling. However, assuming that illness necessarily has a message is also positivist. The message may be the one that interactively arises through the dialogue with affliction. We co-create the message with the illness. What emerges may not have been present at the moment of affliction. A member of the workshop speaks up about using narrative methods with women who have received violence from a romantic partner. She now approaches them with genuine curiosity, with what Harlene Anderson and Harry Goolishian of the Houston-Galveston Family Center called a "not knowing" stance. She learned she could ask legitimately about the ways in which the women recipients of violence still loved their partners. In her old model, victims were not allowed to love perpetrators. Through narrative means, she could embrace the rich complexity of relationship in which love and violence can co-exist She shared how this awareness removed her from the frustration of being a social worker who was angry at women who returned to men who beat them. She could be less judgmental. She could be curious about how they would do this and the value of love over battery. She came to understand violence as a visitor into a situational relationship which deserved query. A part of us hates the violence. A part of us is angry at the person who is violent. A part of us still loves this person. How can these parts, these characters negotiate? How can you, the person who receives the violence, balance your anger, your love, and your desire to avoid being hit? How can we negotiate this? She told us how this approach was so much more effective than her previous black and white stance. When she allowed her clients to acknowledge the love, they could actually more successfully problem solve about how to avoid the violence. Narrative paradigms do not oppose biomedical therapies, only the blind reliance upon them. We realize that more levels can be considered beyond the merely biochemical. "What about athlete's foot?" one participant asked. "That can be quickly treated with an anti-fungal medication." "But there is a story there," I countered. "I have had this problem and it came from a story in which I was too busy to dry between my toes after showering at the gym. Going a little slower and doing self-care became an important theme that had manifestations in other areas of my life. I could take a narrative approach to athlete's foot by wondering about all the other areas in which bit of self-care could prevent a more serious problem from developing." Here I was proposing that everything that happens to and inside of our bodies involves story. Because our bodies are our lives, whatever happens to and in them has ongoing meaning and purpose, even if it didn't when it occurred. Illness takes place within a field that remains to be discovered and explored as potentially part of the healing process. This is also the message of Brian Broom, a professor of rheumatology at the University of Auckland Medical School in New Zealand, in his book, Meaning-full Illness. He writes how exploring the field of relationships, locales, and situations surrounding the illness can allow its meaning to appear and lead to its healing. Again, for him, illness serves as an invitation to enter into a dialogue. Even when illness appears to have no intrinsic meaning, we can seize the opportunity to construct meaning , to re-vision ourselves, to re-construct our lives. Brushes with mortality have that life-changing effect. Professor Hardy in the UK studies spiritual transformations and found a common antecedent to be near-death experiences. We humans have the unique capacity, as existentialists like Victor Frankl have written, to create meaning where none was before. This arises from our inherent, intrinsic capacity for storying, for applying our biologically primed narrative capacity to the physical world in which we are embedded. I'm happy to live in a storied world of magic and purpose more than a material world of randomness and meaninglessness. I'm happy to believe that my efforts at elucidating the field around an illness and identifying the characters who move in that field, matters. The rules of evidence also differ for me. I'm not as interested in mass produced, randomized, controlled trials, as I am in whether or not the people I see grow and change in meaningful and important ways which others can recognize. I use outcome measuring instruments like the MYMOP (My Medical Outcome Profile), Duncan and Miller's Outcome Rating Scale, and more. I do care if I'm effective or not. But I also listen to the stories I'm hearing and ask whether or not they're changing. The affliction, the label placed upon the suffering, gives us an excuse to sit and talk, to start a conversation in which change and transformation could occur. If it's early, for instance, in the course of metabolic syndrome, we could transform our lifestyle and loose the illness. If it's late, perhaps our goal is comfort and meaning, especially after the renal failure and blindness have occurred. In my experience, asthma also always responds to dialogue; less so, COPD. Cancer is its own unique set of complications. We can also develop strategies for interfacing with the remainder of the medical system. Recently a patient of mine had her second bypass surgery in 11 years. I knew it was coming because I could not get at the stories that kept her from controlling her blood glucose adequately. After it happened, however, the young specialists had a bevy of protocols on which to place her. If she took all their recommended medications, she would have been taking 12 different drugs each day, many of which interacted and all of which had side effects. We generated a plan of demanding end points from the specialists. What was the goal? Rather than take everything, she wanted to take only those medications which would clearly advance her capacity to walk extended distances and up and down stairs without shortness of breath. She proposed to the specialists to assess each drug individually for its contribution (or lack thereof) to her walking and climbing capacity. If it didn't make a difference, probably it was unnecessary, even though recommended by protocol. This was a new story for the specialists (but a common one to geriatricians who often joke about killing the patient to cure the illness). I was able to help this patient to negotiate with her specialists in a way in which she got what she wanted and they learned to respect her. We are still working to find meaning in the heart disease through co-authoring a story called "adventures of the heart". It is a work in progress but one that has already comforted her despite her limitations. Thus, illness or other afflictions present opportunities for meaning-making, through dialogue with the illness, through allowing it to speak and be heard, through querying it, through negotiating with it, through transcending it, through the myriad of relational opportunities available. Sometimes this allows the illness to calm itself, to depart, and sometimes it doesn't. Always the opportunity exists, however, to make more meaning than existed previously. This is the invitation that every affliction makes -- to co-create meaning and value.

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

Sweat Lodge, Prayer, and Community

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