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.

Reflections after a Hypnosis Workshop

I spent this weekend in Wakefield, Rhode Island, co-teaching a workshop with my friend Peter Blum, a hypnotherapist from Woodstock, NY. Peter and I have co-taught previously in Woodstock, and once in Malibu, California, and even once at the annual meeting of the National Guild of Hypnotists in Massachusetts. We were at the largest non-residential yoga center in the Northeast, All That Matters. We had the pleasure of staying with Joan and David Dwyer (who started All That Matters) in their lovely three story house, nestled deeply in the Rhode Island woods. They have five children, one of whom we met, Greg, who was home for the weekend. Peter and I combine his Ericksonian approach with my narrative foundation to produce a hypnosis of changing stories to change lives. I had the opportunity to demonstrate a narrative interview with a man who didn't believe in stories, only in the truth. My challenge was to show him (and the participants in the workshop) how a narrative approach could be relevant even to him. Our new friend whom we'll call Mark, had a large story of people who did him wrong, from doctors who failed to diagnose his rheumatoid arthritis to investigators who failed to investigate his wife's murder which had happened twelve years earlier. Mark was a challenge because he wanted to tell all the details of the conspiracy that led to his wife's murder and the cover up of that murder. "Let's get "just the facts'," I said to Mark. I decided to focus on his son with whom he was currently estranged. "Let's focus on what your son would see as the facts." Mark agreed with that. Through great effort at stopping Mark every time he wandered into his conspiracy story, I was finally able to arrive at his view of his son's view of the facts. Mark agreed that his son would have said that he was born in Rhode Island, an only child. His father had been ill and unable to work for as long as he could remember. His father suffered from a mystery illness which no doctor had diagnosed that included migratory joint pain. Tests had been run and never showed anything. His mother supported the family, working as an investigator for the Rhode Island State Police. Finally when Mark's son left for college, a rheumatoid arthritis titer was positive and a rheumatologist finally diagnosed his father with that condition, started him on the appropriate medication, and his father improved dramatically. Things were looking up until his mother died in a car accident on an isolated highway at 4 in the morning near the time of his graduation from college. For the first year, he did his best to comfort his father who was distraught, but he tired of his father's unfolding conspiracy theories about how the accident being a murder covered up by politicians. Mark's son proceeded to find a good job, get engaged, get married, have a child, get divorced when his wife found someone else, find a new relationship, get remarried, and have two more children. His youngest was 3 months old at the time of my interview of Mark. That had kept him busy and removed from his father's struggles to expose government corruption. Now I was ready for Mark's story, which involved incompetent doctors who failed to diagnose his obvious problem for over twenty years followed by corrupt lawyers, police, and politicians who covered up his wife's death because she was investigating them. Mark had spent the past twelve years trying to find someone to declare his wife's death a murder and to expose the government corruption she had been investigating. The story was convoluted and difficult to understand, and in so many ways, never-ending. Mark was angry with his son for not believing the conspiracies (the truth, as he said) and for not picking up the torch to expose corruption. I had found a potential place for intervention. "Do you see how there could be two stories here, both of which use the same facts?" I asked. "The facts are that you were sick for a long time, finally someone made a diagnosis and treated you in a way that helped you, and then your wife tragically died. In your story, a conspiracy murdered her. Your son, on the other hand, accepts the official story, that she died in a car accident. Of course, Mark quickly interjected, "The truth was that she was murdered." "Of course," I answered, "but that story doesn't work for your son who's at a different stage of life than you and is preoccupied with relationships and having children and getting divorced and finding new love and getting remarried and having more children. His concerns are more immediate and different from yours," "He just doesn't want to see the truth," Mark said. "That may be," I asked, "but are you interested in being close to your son?" "Yes," he said, but not if I can't speak my mind. That reminded me of a movie which I described to Mark. In this movie, which several people in the workshop had seen, a man invents the variable speed windshield wiper and takes it to a big car manufacturer who steals his idea and pays him nothing. He spends the next 15 or more years of his life fighting for justice, even learning how to function as his own attorney, when he runs out of funds to pay legal fees. Eventually he wins his lawsuit but at the cost of his marriage and his relationships with his children and all of his money. Mark became really animated at hearing about this man. "That's great," he said. "He finally found justice." "But at what cost?" I countered. "The cost doesn't matter," Mark said. "Justice is worth it." "That's where you and your son disagree," I said. "The two of you have different stories about what justice is worth." Mark then argued that his story was the correct one. "If you want a better relationship with your son," I said, "you might have to respect his story as valid for him even though you wouldn't choose it. My reaction to that movie was the same as your son's might have been. Justice wasn't worth the price the man paid," "That's just wrong," Mark said. "We all have to fight for justice." "And that's where we disagree," I said. "So, if I was going to work with you, I probably couldn't help you find justice, because that's not my specialty. I know lots of situations in which injustices occur. I'm aware that governments are often corrupt and that bad things happen to good people. Just yesterday I saw a documentary about three men convicted of a murder in 1993 on flimsy circumstantial evidence who were finally exonerated with DNA. For every case that ends well, there are probably five that don't. I could help you find a way to respect your son's story and act around him in such a way that you get to see your grandchildren more often." Mark's other complaint was that people didn't want to be around him. They got tired of hearing his story and avoided him. So I added, "I could also help you learn better storytelling skills so you know when to tell the really short version of your story, like, I was sick for a long time and then my wife, and to hold the long version for those less common situations when your with people who actually want to hear about conspiracies and corruptions." That approach didn't really appeal to him either, but the demonstration was concluded. The moral of the story is that we can't help everyone, and we can be clear about what we can do and what we can't do. I asked Mark to agree not to talk about conspiracies or corruption for the rest of the day and then talked about my approach to people who have too big a story, which is to encourage them to write their book as therapeutic activity. I have two clients who are doing that to good results. Another client got amazing benefit out of writing a "zine" about her life. (Zines are short novellas written almost like comic books.) We can also sometimes enter into the story and work from within the story. I told a story about a young woman whom Barbara, my co-therapist, see. This young woman believes that aliens are broadcasting thoughts into her mind and trying to control it. Many had tried to dissuade her from that conviction to no avail. We enthusiastically entered into the story to help her to find ways to protect herself from the aliens. This approach is working because we are strengthening characters within her mind that can protect her from the aliens. We suggested that dogs are impervious to alien invasion because they lack a pre-frontal cortex. Therefore, the aliens can't control them and she could draw strength and comfort from her dog, which she is doing. We began studying movies with her, like Invasion of the Body Snatchers, and collected strategies that have been used in the past to protect minds from alien takeover. In the midst of this, our client has started exercising, eats better, has made new friends, and is doing things to get healthier. We were able to form a coalition with her. The key was her willingness to work with us. Following my interaction with Mark, Peter demonstrated hypnosis with someone with a physical affliction. A participant volunteered who had a dislocated toe. That was a greaexample, because some people said, "how can a dislocated toe have a story?" However, the toe wasn't healing as fast as expected. A story did emerge about the toe being at the end of the gall bladder meridian and the injury relating to moving too fast without taking proper self-care. So, even toes have stories that could be told. Every aspect of our lives is multiply determined with potential explanations on many levels.

Mind, Body, and Unexplained Symptoms

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

Narrative Practices for a New Year

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

Reflections upon Teaching Statistics Again

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

Reflections upon the Transition to Private Practice

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

Accountability

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