Reflections After Sundance No. 2, 2011

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

Reflections after Sundance 2011

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

Sweat Lodge, Prayer, and Community

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

Adolescent Addictions and Las Vegas

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

Short Sighted Health Insurer Policies Which Refuse to Pay for Healing & Preventive Services Hurt Patients, Cost Fortune

The health care debate continues in Washington, D.C. and across the nation. What impressed me this week was the Republican assertion that Americans were by and large happy with their health insurance. I don't know anyone who is happy with their health insurance, and, as a physician, I know many people who have health insurance and use it. Advocates for President Obama's plan point out that people will have much better coverage of services under their plan even though individuals will pay 10 to 13% more. Republicans argue that people would rather keep the plans they have and save the 10 to 13% increase in premiums.

I'd like to weigh in on what people don't get with today's health insurance, because I know what I don't get paid by insurance to do. If I see anyone more than once per week, I don't get paid. I remember my surprise when I saw an 86 year old woman with heart failure daily in order to keep her out of the hospital (her wishes) and as able to do so. Medicare, however, paid me only for the first visit of the week and denied all the others as medically unnecessary. Had I admitted her to the hospital (she certainly would have qualified), presumably Medicare would have paid the hospital, though they might have scrimped on my daily visits to her. Heart failure is the number one cause of geriatric admissions to hospital. Imagine the savings that might accrue if we had geriatric home teams who could manage such patients outside the hospital. However, contemporary health coverage will not permit that.

Here's another example. I work with many seriously mentally ill people. The most common diagnosis they receive is schizophrenia. I work with a small subset of these patients intensively, for no charge (since no one will pay me). The patients I see once or more per week use much less medication and have many fewer hospitalizations than the patients I see once per month (what insurance will allow). I like to work with these people in a group format because they learn from each other. Insurance will not allow that either. The cost of the medication that the insurance does cover ranges between $500 and $1000 per month. I can usually keep the patients with whom I work more intensively below $200 per month in medication costs.

What's also important, but rarely considered by today's insurance companies, is the level of suffering. I imagine insurance executives sitting in board rooms thinking that we doctors would see patients daily for hours if we could and that nothing would come of it besides our income. I don't even think that happened in the heyday of psychoanalysis when people were seen daily (that's been rare since 1970). I've submitted a paper for publication on the outcomes of 51 people diagnosed with schizophrenia whom I saw for more than four hours per month over several years. Over 80% of these people were doing well and were off medication at seven year follow-up. Imagine the cost savings if we were actually paid to help such patients. People with schizophrenia die, on average, 25 years before age-matched controls without that diagnosis and the last year of their life is quite expensive.

In fact, 70 to 80% of the total amount spent during a person's life is spent in their last year of life. That could be reduced if doctors spent more time talking to families, which is also not currently often reimbursed. In fact, the patient must be present in order for insurance to be billed, and that is sometimes not in the patient's best interest. Sometimes it is very important to have conversations with family members that the patient may not want to hear.

I remember a 104 year old man for whom the family wanted full resuscitation efforts were his heart to stop. The insanity of this was that chest compressions would have probably killed him by breaking all his ribs and bruising his heart. We were able to spend several hours discussing this with family members over two weeks and eventually consensus was reached for a "do not resuscitate" order. My bill for these meetings was denied by Medicare as medically unnecessary. Imagine the cost of transporting him from the nursing home with ambulance sirens blasting, paramedics working, and then the ensuing chaos that would have ensued. I did see this happen once and watched the code team half-heartedly pursue resuscitation of a 108 year old man. Not a single person thought it would work, but the family insisted, and at least a $20,000 hospital bill was generated.

Another example comes from a chronic pain patient. People with chronic pain are largely failed by the medical profession. Within the medical model of a pill for every woe, the pill offered is often a narcotic. Narcotics lead to tolerance and tolerance is a sign of addiction.

Once people are addicted, physicians will often then refuse to treat them. What now! Chronic pain, however, is largely a central nervous system phenomenon. The brain learns about acute pain from a sudden injury and then changes and adapts to continue to feel that pain long after the injury has stopped transmitting pain signals. This fact is part of virtually every continuing education course for physicians in chronic pain, but largely ignored in practice because the ways of approaching central nervous system change are largely not covered by health insurance. Cognitive behavior therapy, hypnosis, narrative therapy, neurofeedback, biofeedback, and many others have shown useful in studies, but are not covered. Only visits to physicians for medications and sometimes the medications themselves are covered. I have worked with many patients to reduce chronic pain using these tools, and insurance has paid me less than 10% of the time.

Success is irrelevant to the insurance industry because what matters is short term (quarterly) profit and loss, not people's health in the long-term or even long-term cost-savings. Take my patient Mary as an example. Mary was referred by a mutual friend to work with me to reduce pain and restore functioning. I worked with Mary for eight sessions and we started making progress toward reducing medication and reducing pain. Then Mary heard from her insurance company that they would not pay any more than 8 sessions. Because we were making progress, I offered to work with Mary for whatever she could afford, even if it was only $5 a session. She declined saying she only wanted to do what her insurance would cover.

Why do I see select patients for little or nothing? Because I need to feel effective. Within the constraints imposed by contemporary health insurance, rarely can I help people with chronic disease and suffering in a meaningful, transformative way. I have invented ways to circumvent this healing circles that are peer-led or relatively leaderless in which everyone helps everyone else and no fee is charged. It is the patients whom I see for next to nothing who are improving and reducing costs to the health care system. The ones insurance cover are not getting well very fast.

We should consider this in the health care debate. Data is available for discussion. Numerous studies have shown that 80% of primary care visits to health care practitioners involve the ordinary suffering of daily life and not diseases that need treatment, yet we throw pills and potions at these woes as if that is their solution.

Health care reform will never work unless we find cost-effective ways to address the ordinary woes of daily life and stop attempting to medicate them away. This will not happen until insurance coverage is expanded to include coverage of prevention and non-pharmacological therapies. I would be thrilled if we moved toward a system that rewards good outcomes.

If I were paid in accordance with people's getting better instead of compliance with a list of covered services, I would be much better off finacially and might find more effectiveness and sense of satisfaction from within insurance reimbursed services. That would be a novel experience I would welcome.

The Narrative Interview: Day 3 of the Australian Journey

Of course, the bigger news than our Australian adventure is the tragedy of the earthquake in Japan and the accompanying tsunami, which remind us of our relative insignificance relative to the forces of Nature. We suffer with the rest of the world for those who were harmed in this natural disaster.

However, our trip continues and today we are in Warburton, Victoria, and met some members of the local community who work with children. I gave a lecture at the Warburton Town Hall and, of all people, the Governor of Nambe Pueblo in New Mexico, attended. We were able to chat afterwards and I learned about "The Gathering of Eagles", which will take place at Nambe Pueblo in New Mexico during the last week of July. We were staying at Sancta Sophia Meditation Center in Warburton, a center started by a Carmelite, Sister Kathleen, and a Benedectine, Father Ken. Their mission was inter-religious dialogue, of which we were having much.

Next we focused upon how we would interview within a storied paradigm as compared to diagnostic interviews based upon conventional diagnostic categories. I had the opportunity to interview an aboriginal woman who had defied diagnosis for 12 years except for her asthma and back pain. Her main symptom was severe fatigue, for which her doctors had just prescribed an antidepressant. We quickly reviewed her laboratory studies which were largely unremarkable as is so often the case. There were some signs of chronic, low grade inflammation like a slightly elevated erythrocyte sedimentation rate, a slightly increased platelet count, a slightly low level of triiodothyronine, a slightly reduced estradiol level, a slightly reduced blood hematocrit, and a slightly elevated evening cortisol level, none of which were diagnostic of anything. Her symptoms consisted of some menstrual irregularities, some extra ovarian follicles, moderately severe asthma, back pain, and stomach pain from duodenitis. She had seen conventional doctors and natural healers, including a traditional Chinese doctor, a reflexologist, and a naturopath. She had been raised in an urban environment and had a large aboriginal extended family and many contacts, but none of them were elders who did healing, or it had never occurred to her to ask this of her relatives and acquaintances. Nothing had really helped her. The Chinese medicine had resolved her canker sores, which wasn't a major problem for her anyway. The reflexologist had successfully mapped the sore areas on her foot to the body areas that were problematic, but that hadn't changed anything, however amazing it was. The naturopath had tried eliminating all sugars, pork, spice, sauces, dairy, soy, and wheat, which had made no difference. The supplements he prescribed had worsened her stomach pain. She had recently started eating bread and dairy again and was no worse the wear, though she had realized that especially rich foods gave her more stomach discomfort, bloating, and constipation. She had taken the birth control pill, Yaz, to regulate her menses as well as Accutane for acne.

Then I began to look for the story. The last time Sandra remembered being completely well was when she was age 16. That was when her partner, with whom she had been living since age 13, killed himself. She sadly moved back home only for her mother to die two years later. She found another partner with whom she had two children in two years. Then, her favorite aunt died unexpectedly. That's when she had her first asthma attack. Back pain followed suit. Sandra didn't have a theory about how she got asthma but thought that her back pain was the result of carrying two young children around. She continued having moderately severe asthma and back pain for ten years until she became pregnant with her third child. During that pregnancy, her asthma and back pain improved, but then they came back with a vengeance after she gave birth. Suddenly a new very severe symptom appeared -- absolute and complete fatigue, which had continued unabatedly severe until today.

During all this time, Sandra had been running an art cooperative that her mother had started. It managed a number of aboriginal artists' work and had retail outlets throughout the area. Sandra had some tears as she talked about her mother, who had been absolutely driven to succeed and bring her family out of the relative poverty in which they had previously lived. Sandra's grandmother had also been an accomplished artist, had nine children, but had lived in relative poverty even as she supported Sandra's mother to go to art school and be successful in a contemporary sense.

I asked Sandra what she would be doing if she were well and she said she would be out in the world continuing to expand and grow the business that her mother had started. She worried about the business all the time, even though it was doing well. She feared that her limitations would make it suffer.

I asked Sandra what gifts the illness had brought her. Again, she responded immediately. Without the illness, she wouldn't be spending nearly so much time with her children at home and with her husband. She'd be out working. "Like your mother?" I asked. That led to a powerful, tearful story about her mother and how burned out her mother had become and how desperately she thought her mother had wanted to relax and be with her family and be cared for. Her mother had never had that. She feared that she was becoming her mother and worried that she would die at age 36, the same age at which her mother had died.

"How much help do you have?" I asked.

"Help!" she responded incredulously. "Everyone's too busy with all the things they have to do to help me. " She recited a litany of examples of how her children were too busy with their homework, or too young. Her husband worked 6-1/2 days per week to support the family. Her relatives were equally busy. Slowly it became clear that Sandra couldn't ask for help and wouldn't take it, if offered.

"So," I said. "We have a SuperWoman story! Modern aboriginal woman defies all odds, continues to build her mother's business while raising a family and refuses all help because she can do everything, including leaping tall buildings with a single bound and running faster than speeding locomotives."

"Wonderwoman," she said. "Better costume. Invisible airplane. Lasso." I had to agree that Wonderwoman was more cool that SuperWoman. So, here's the story, I said. And your two dogs fighting (a metaphor for conflicting beliefs) is this: one dog says you have to do it all without help and the other dog says your ill and you can't do it all and you need and have to accept help. "Right," she said.

"So," I said. "Did any of your many health practitioners talk to you long enough to get this story?"

"Never," she said.

"And that's the problem with conventional medicine," I said. "Here's what I'd do next. I'd call a meeting of everyone you know -- family, friends, co-workers, fellow artists -- and we'd do a large talking circle in which everyone got to contribute their story about you to your story, and then we'd brain storm about how everyone could be helpful to you." This made her very uncomfortable since she didn't like to ask for or receive help. "This is the indigenous way, in which community heals people whether they ask for it or not. An aboriginal woman elder in the audience invited her to join a women's circle that she led, "whether she needed it or not." This would set the stage for day 4's discussions on community.

Drug Abuse Prevention; Why do the American media avoid discussing research findings?

This week on American television, as part of its coverage of the 2010 Vancouver Winter Olympic Games, particularly on the CNN Network each morning at the gym were I exercise, the morning news was astir with discussions of Insite, a Vancouver-based project that provides addicts with a safe site to inject, including clean needles. The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.

Why do the American media avoid discussing these research findings? Why are the opinions of uninformed people in towns like Decatur, Georgia, and Cumberland, Maryland, more meaningful than the results of carefully conducted scientific research? Why is evidence-based medicine abandoned when it comes to drugs? Why is the existence of credible research not even mentioned? The best that was done was to mention that the director of the Insite Program believed that lives were being saved. Not mentioned was the hard scientific evidence amassed to back his position. Why does science not matter when it comes to drug policies?

CNN implied that Insite was operating under the legal radar and that the Vancouver Police Department were pretending not to notice its existence. In fact, in 2003, the regional health authority in Vancouver successfully applied to the federal government for a legal operating exemption to pilot Insite.3 This exemption was granted following the release of feasibility data which suggested that Insite had the potential to reduce public drug use and overdose deaths.4,5 Insite was established following prior experience of similar facilities in European and Australian settings. Corresponding research suggested that these facilities had unique potentials to reduce public illicit drug use while promoting the use of sterile syringes and providing emergency care in the event of overdose.6-9 Since opening in 2003, Insite has been a place where people could inject drugs and connect to health care services from primary care to treating disease and infection, to addiction counseling and treatment. Few areas suffer more from the lack of response to research than illicit drug use.1,2

Dr. Evan Wood, Director of the University of British Columbia's Center for Excellence in HIV/AIDS research reported in The Calgary Herald on January 31, 2010, that despite criticisms levied by Conservatives (and the American media), the benefits that Insite provides are real and verified.

Dr. Wood pointed out that drug prohibition has created a massive global revenue stream for organized crime, worth an estimated $320 billion US annually. These enormous proceeds threaten the political stability of entire regions, including Mexico and Afghanistan. In the U.S., where the war on drugs has been fought most vigorously, the incarceration of drug offenders has placed a huge burden on the taxpayer and contributed to the world's highest incarceration rate. Primarily as a result of drug-law enforcement and mandatory minimum sentences, one-in-eight African-American males in the age group 25 to 29 is incarcerated on any given day, despite the fact that ethnic minorities consume illicit drugs at the same rate as white and other sub-populations. Paradoxically, ever-increasing drug enforcement expenditures and incarceration levels have not prevented the drug market from becoming more efficient.

The association between drug prohibition and increased inner-city violence is consistent. A recent international example is the upsurge in severe drug-related violence in Mexico subsequent to Mexican President Felipe Calderon's escalation in the fight against Mexican drug traffickers. Increasing gun violence in Canadian cities has been directly linked to clashes between organized crime groups over the enormous drug market profits.

HIV and overdose death rates are highest in areas where law enforcement is prioritized over evidence-based public health strategies. These harms are significant given HIVs spread beyond its traditional risk groups and its burden on the health system. Each and every case of HIV is estimated to cost $250,000 in medical expenses. For the above reasons, conservative economists like Nobel Prize winner Milton Friedman have long argued that the "war on drugs" does much more harm than good.

Due to their effectiveness, harm reduction policies are now endorsed by all evidence-based scientific consensus bodies, including the U.S. Institutes of Medicine and the World Health Organization. This consensus is based on rigorous reviews of the large volume of international scientific evidence indicating that harm-reduction programs save tax dollars and improve public health by reducing HIV rates while increasing uptake of addiction treatment. To read more from Dr. Evan, see click here

In Europe, more than 65 programs like Insite bring street-based drug addicts indoors where they can be prevented from sharing needles and overdosing while increasing enrollment into addiction treatment. Insite has replicated the European experience, and is undoubtedly the most highly studied health clinic in Canadian history. More than 30 peer-reviewed studies show that Insite reduces public injecting, reduces HIV risk behaviors (e.g., needle sharing), and increases rates of addiction treatment. Studies seeking to identify potential harms of the facility found no evidence of negative impacts. Studies were independently peer-reviewed and published in top scientific periodicals, including the New England Journal of Medicine, The Lancet and the British Medical Journal.

During the period from March 10, 2004 to April 30, 2005, 4,764 individuals registered to use Insite. Heroin was used in nearly half of all injections, and cocaine was injected 37% of the time. There were 273 witnessed overdoses, none of which resulted in a fatality. There were also 2,171 referrals to addiction counseling and other support services. These early results indicated that Insite was being successfully integrated into the community. The facility was attracting a wide cross-section of injection drug users, and staff were successfully intervening in overdose events on site and actively referring drug users to addiction treatment and other services.10

A 2006 study showed that Insite was attracting a large number of hard-to-reach intravenous drug users and that the existence of the facility presented an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject. Finally, the facility was also an important point of contact for HIV-positive individuals who were not yet participating in HIV care and treatment.11

One concern prior to the opening of Insite was whether the facility would encourage injection drug use by making drug injection easier and more comfortable for intravenous drug users. Therefore a study was made to determine whether or not the opening of the facility would be accompanied by a worsening of community drug use patterns. The drug use behaviors of 871 intravenous drug users were observed in the one year period before the opening of Insite and in the one-year period after. The drug use behaviors studied included the rates of relapse into injection drug use among former users and the cessation of injection drug use among current users. The study found that after Insite opened there was no substantial increase in the rate of relapse into injection drug use among former users (the rate of relapse was 17% prior to the opening and 20% after). There was also no substantial decrease in the rate of injection drug use cessation among current users (the rate was 17% prior to Insite's opening and 15% after). This research showed that the benefits of Insite on reducing the high-risk behaviors of intravenous drug users and on increasing public order were not offset by negative effects on drug use patterns among Vancouver's intravenous drug using population.12

Critics suggested that the availability of a supervised injection facility might discourage drug users from seeking treatment for their addiction. A study was conducted to examine the effect of Insite on the use of detoxification services, which is the entry point into the addiction treatment continuum in Vancouver. The study followed more than 1,000 Insite users between December 1, 2003 and March 1, 2005. Of this group, 185 (18%) began a detoxification program at some point during the study period. Individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently. The study also found that contact with Insite's addictions counselor significantly increased a person's chances of enrolling in detox. Contrary to fears that Insite might be deterring drug users from seeking treatment, these findings strongly suggested that Insite was facilitating entry into detoxification services among its clients.13

In another study, researchers measured the effect of Insite on the use of detoxification services by comparing rates of detox service use among injection drug users in Vancouver in the year before Insite opened and in the year after it opened. The researchers also investigated whether those individuals who attended Insite and enrolled in detox were subsequently more likely to enroll in methadone maintenance or other drug treatment programs. They learned that, in the year after Insite opened, there was a 33% increase in detoxification service use, compared to the year prior to the opening of the facility. The study also showed that Insite clients who entered detox were 1.6 times more likely to enroll in methadone treatment and 3.7 times more likely to enroll in other forms of addiction treatment. As well, individuals who entered detox visited Insite less frequently in the month after enrolling in detox services than in the month prior to enrollment. This research indicated that Insite encouraged intravenous drug users to enter detox. It also suggested that drug users who enrolled in detox were more likely to remain in subsequent treatment programs and reduce their use of Insite.14

I don't have an answer for why ideology trumps scientific evidence in the United States and its media. Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?