Category Archives: Re-humanizing Medicine

Thoughts from the Clinical Director: Being Lost

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I am a week late in writing these fortnightly thoughts, as I was traveling back in the States for a couple of weeks. Right now I have two homes, one here in New Zealand and one back in the US. I have to admit that I feel a bit lost at times, but I think about the clients at BRC and how much more lost they must feel, lost in psychosis, lost in drugs and alcohol, many lost from families and lost from trusting human relationships. Those are much more painful conditions of being lost. I see the problem of being lost as one of the primary things that we work on in a rehabilitation setting as opposed to a mental health centre or an acute inpatient ward, where the focus is primarily on treating symptoms.

One of my favourite writers, Rebecca Solnit has written a wonderful book called A Field Guide To Getting Lost. She explores all the ways that people can get lost, but as always, she searches for how being lost is part of the human condition and can even lead to growth and transformation (as well as risk destruction and dissolution). She quotes the Greek philosopher, Meno, as asking “How will you go about finding that thing the nature of which is totally unknown to you?” (4). She goes on to say:

The things we want are transformative, and we don’t know or only think we know what is on the other side of that transformation. Love, wisdom, grace, inspiration—how do you go about finding these things that are in some ways about extending the boundaries of the self into unknown territory, about becoming someone else? (5).

I often think about this seeming paradox in our work with clients and in personal growth: to what extent are we working to support our clients to “become someone else” and to what extent are we supporting them to become more authentically “who they are,” or to realize their potential? I sometimes get uncomfortable talking about potential, because that seems to imply that someone is less than who they could be. It all gets pretty complicated sometimes when you start talking about change and transformation. But I would definitely say that the work that rehabilitation and recovery requires is transformative and we are asking our clients to extend their boundaries of self to include new possibilities. You should know me well enough by now to know that the next thing I am going to say is that as staff working in rehabilitation we need to extend the boundaries of ourselves as well. One of the ways that psychiatrist Carl Jung looked at psychotherapy is that the therapist has to get lost along with the client and then act as a guide to help both of them become found. As Solnit writes, “Sometimes gaining and losing are more intimately related than we like to think,” (38). That implies that if we seek to gain anything, we must tolerate becoming lost, and possibly even seek out becoming lost. “Not till we are lost, in other words, not till we have lost the world, do we begin to find ourselves, and realize where we are and the infinite extent of our relations,” (15).

Even though it is necessary for finding ourselves, being lost also has serious risks and that is what we and the clients struggle with at BRC. How can we reach someone who has lost hope? How can we support clients in a positive way who are lost in repetitive cycles of addiction, depression, psychosis, trauma or violence? This is where the art and skill of rehabilitation comes in. This is where we have to be willing to become lost ourselves and to say, “I really don’t know what the **** to do next!” In trying to reach clients, we often have to realize that the text book is not working and we have to find it within our hearts to be patient with ourselves and with clients when we are in these lost spaces. I sure wish that I could say that I was often successful in this work. I cannot say that I am. It often seems that many of our clients make small changes and some clients seem not to change at all. I still have the unshakeable belief, though, that the work we do matters and makes a difference. When we go looking for someone who is lost and when we maintain the hope of a searchlight we are offering clients a pathway back from wherever they are lost. Sometimes that is all we can do is to stubbornly maintain hope. I may have already quoted Vāclav Havel in an earlier column, but it is he who I always turn to when I am trying to maintain my own hope when I am lost or when I am trying to reach someone who is lost. “Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out.”

Since I am in this 90 day period of leaving Buchanan, I have found this website that allows me to calculate how many days are between two dates. At this point it is down to 62 days that I have left at Buchanan. What can I do in that short amount of time? I have to let go of any grand plans for transformation and really just focus on connecting to people and starting to say goodbye. I have to admit, I feel a bit lost at times, but I know we are all working together and that gives me some comfort.

 

Lost

Stand still. The trees ahead and the bushes beside you
Are not lost. Wherever you are is called Here,
And you must treat it as a powerful stranger,
Must ask permission to know it and be known.
The forest breathes. Listen. It answers,
I have made this place around you.
If you leave it, you may come back again, saying Here.
No two trees are the same to Raven.
No two branches are the same to Wren.
If what a tree or bush does is lost on you,
You are surely lost. Stand still. The forest knows
Where you are. You must let it find you.

David Wagoner

 

It is I who must begin

It is I who must begin,

Once I begin, once I try—

here and now,

right where I am,

not excusing myself

by saying that things

would be easier elsewhere,

without grand speeches and

ostentatious gestures,

but all the more persistently

—to live in harmony

with the “voice of Being,” as I

understand it within myself

—as soon as I begin that,

I suddenly discover,

to my surprise, that

I am neither the only one,

nor the first,

nor the most important one

to have set out upon the road.

Whether all is really lost

or not depends entirely on

whether or not I am lost.

Vāclav Havel

 

Some (Parting) Thoughts from the Clinical Director (26/7/13)

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It is with great sadness that I am writing to tell you that I am handing in my 90 day notice for my resignation from Buchanan Rehabilitation Centre and Auckland District Health Board today. That means that my last day at Buchanan will be Thursday, October 24th, 2013.Why am I leaving? A client at BRC recently asked me if I was leaving because of something he had done. That is so not true at all, I am not leaving because of anything at all having to do with BRC or what anyone has done or hasn’t done. I am leaving because it is time for me to leave. My wife, Mary Pat and I have decided to move back to the States and we’re in the process of relocating to Seattle, a city in Washington State in the Northwest corner of the United States, not too far from Canada and the city of Vancouver. I will be taking a job at the Veterans Administration, which is a federal job working with war veterans. (It will be a bit of a full circle for me as my first job was at the Omaha VA and the University of Nebraska). I will be working in a clinic that integrates primary care and psychiatry and I’ll also do a day of telepsychiatry over the internet, connecting with patients who live in rural Washington, Idaho, Montana, Wyoming and Alaska. I will also have a joint appointment with the University of Washington, so that I can teach – which is one of the things that I love the most and which I am very enthusiastic about; and I’ll also have a paid writing day each week!

Seattle with Mount Rainer looking South

 
Seattle with Mount Rainer looking South

What is Seattle like? It is a beautiful city set in some of the most beautiful mountains, forest and ocean in the United States. I have always been particularly fond of the Olympic National Park where I have spent many memorable camping trips. Both Mary Pat and I have family in Seattle and we also have a lot of really great friends there.

Seattle with Olympics, looking West

Seattle with Olympics, looking West

Leaving Buchanan is really difficult for me, because I love it so much. I am so grateful to have had the chance to work here, and it has been a privilege to have served as Clinical Director. I only wish I could have done more and that I could have stayed longer and sometimes I wish there were two of me so that I could both stay at BRC and go on with my new life. Why am I leaving then? Well, I said because it is time for my family to relocate back to the States. I think about a quote I have always liked by Henry David Thoreau about why he left the cabin he built on Walden Pond, where he lived for 2 years, 2 months and 2 days (I will have been at Auckland District Health Board for 3 years 3 months and 5 days – you might think I stayed a couple days too long!). Anyway, I will share a long quote from Thoreau:

“I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to live, and could not spare any more time for that one. It is remarkable how easily and insensibly we fall into a particular route, and make a beaten track for ourselves. I had not lived there a week before my feet wore a path from my door to the pond-side; and though it is five or six years since I trod it, it is still quite distinct. It is true, I fear that others may have fallen into it, and so helped to keep it open. The surface of the earth is soft and impressible by the feet of men; and so with the paths which the mind travels. How worn and dusty, then, must be the highways of the world, how deep the ruts of tradition and conformity! I did not wish to take a cabin passage, but rather to go before the mast and on the deck of the world, for there I could best see the moonlight amid the mountains. I do not wish to go below now.

I learned this, at least, by my experiment; that if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours. He will put some things behind, will pass an invisible boundary; new, universal, and more liberal laws will begin to establish themselves around and within him; or the old laws will be expanded, and interpreted in his favor in a more liberal sense, and he will live with the license of a higher order of beings. In proportion as he simplifies his life, the laws of the universe will appear less complex, and solitude will not be solitude, nor poverty poverty, nor weakness weakness.” (H.D. Thoreau, Walden)

Dave at a Replica of Thoreau's Cabin

Dave at a Replica of Thoreau’s Cabin

So, now that I am leaving, what next? Well, Adele, our manager at BRC, and I have been talking about this for months and now we will launch into action recruiting a new clinical director to take over my job. We hope that this goes smoothly and that we find someone with values that match those of Buchanan, where clients and staff continually have the opportunity to grow and learn together and to bring the best of the heart and the mind to work every day.

I will continue to keep you posted with our progress of finding a replacement and I’ll continue to write these fortnightly “Thoughts.”

I will tell you that I will be away for a few weeks during the next 90 days. I am heading to Seattle to see Mary Pat (and our cat, Sofia, who recently made the journey there) and to take care of some things with my new job. I’ll be away August 6th and I’ll return to work on August 19th. I also have had a conference proposal accepted in Brisbane for the Health of Health Professionals conference and I’ll be away from October 2nd until October 14th. Otherwise I’ll be around BRC working business as usual, although I’ll be starting to gradually say goodbye to all the wonderful clients and staff at Buchanan.

Thank you for everything,

Dave

Thoreau Quote

Thoughts From the Clinical Director: Soft Institutionalization

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We all work in rehabilitation because we want to help other people, right? Giving more help is always good, right? Well, not always. I sometimes have talked about the difference between help and support. Where help is doing something for someone that they cannot do for themselves and support is creating an environment in which a person learns to help themselves – i.e. learn and grow. The challenge of rehabilitation is an act of continuous triage in which we are always adjusting our expectations of what clients can do for themselves, encouraging them to reach a little bit beyond their current ability and comfort zone. If we expect too little, they don’t grow. If we expect too much, they fail or lose hope and then we put in even more help which can maintain them in a state that requires a high level of input from staff, in other words: institutionalization.

Most of us at Buchanan understand that human beings deserve human rights and that people should be supported to live as independently as possible. But sometimes our desire to be kind by over-individualizing care or overly-lowering our expectations of what are clients can do for themselves leads to de-skilling and dependency. While most people have come to see that institutionalization is a harmful thing to the human spirit, we still inadvertently bring about dependency in our clients through a distorted form of kindness – this is what I call soft institutionalization. Growth and learning require a certain amount of destabilization and discomfort and mistake. If we try to shelter clients from destabilization, discomfort and mistake, then from our kindness we are creating soft institutionalization.

Soft institutionalization occurs as the result of a series of small things that prevent a person from taking on more responsibility. I sometimes think of this as the “negative Buchanan bubble.” This is where a client appears to be functioning well at Buchanan because of numerous small things that we do to shelter them from the reality of responsibilities that they will have in the community. This creates a kind of pseudo-independence. If we shelter clients from the consequences of their actions, we interfere with learning opportunities.

Some examples of soft institutionalization would include: providing transportation for clients instead of challenging them to take the bus, keeping them at Buchanan past the time that they are actively learning and growing, lowering our level of expectation to a person’s current level of functioning instead of always challenging them out of their comfort zone, and making exceptions to BRC/ADHB policies (what in the outside world is called reality) to promote patient comfort over adaptation. While it is true that reality in the community can be harsh, the goal of rehabilitation is to provide clients with the tools and skills to adapt as much as possible to that reality. The goal of rehabilitation is not to try to create an alternate reality that shelters clients from discomfort as that prevents learning opportunities. Everyone at BRC (staff and clients) should be on a journey of growth and learning – that is what working in rehabilitation is all about.

After my last “thoughts” column, Mars had written a nice response and she said that I could quote her statement, “good will always continue,” this was in regard to the question of when is enough, enough? The good that we do at Buchanan, in terms of compassion and inducing hope, does stay with people after they leave. I would add to this that growth will always continue. If we, as staff are continually growing, we teach by good example. If we have taught clients growth while they are at BRC, that growth will continue. If we have not modeled growth and taught growth, then we have not done any real rehabilitation work.

I know this concept of “soft institutionalization” is a difficult one and I do not feel I have totally explained myself on this topic. It is another “work in progress” in which I am still growing.

 

The Real Work

There is one thing in this world that you must never forget to do. If you forget everything else and not this, there’s nothing to worry about; but if you remember everything else and forget this, then you will have done nothing with your life.

It’s as if a king has sent you on a journey to do a task, and you perform a hundred other services, but not the one he sent you to do. So human beings come into this world to do particular work. That work is the purpose, and each is specific to the person.

You say, “But I spend my energies on lofty enterprises. I study jurisprudence and philosophy…and medicine and all the rest.” But consider why you do these things. They are branches of yourself…but remember the deep root of your being.

(Rumi)

Thoughts From the Clinical Director: When is Enough Enough?

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[Isn’t this interesting! For this fortnightly installment I went back to my first draft I wrote when I first thought about this project, June 11, 2012 – one year ago! It is interesting to read this now, to look back at where we were and at how much great work we have already done addressing some of these issues. For that opportunity to look back, I won’t edit this, so please bear in mind that you are reading something written one year ago. I’ve made a few small comments, in brackets, in the text, but otherwise it is what I wrote one year ago this month. Special thanks for the poem that Sue Bailey supplied when she realized that it was by the same author of the poem about the spontaneous community that sprang up around the distressed Palestinian woman in the airport lounge.]

This is the first in what I am hoping will be a series of weekly thoughts from me about our work at Buchanan. I know that we are all very busy and that we all work very hard. I know that our daily work is often so crisis-driven and that we all have so many meetings, that we don’t have the time and opportunities to sit down and really talk together about our work. I am working on creating the time and space for such important discussions through the Recovery Forum, the working groups on Substance Use (AOD) and on the Recovery Culture; and I know we really need a planning day as soon as we can get that organized – however, it just seems that this isn’t enough, what more is needed and what more can I do? Until we can have these dialogues in person, maybe sharing my thoughts with you can help you to understand what I wish for – for Buchanan. Maybe this can get us all starting to think about how we do things and what is working well and what could work better.

Please do not feel obligated to read these messages. I offer them with the hope that they will be supportive and promote dialogue; I don’t want them to be just one more thing that you have to read during the week. I am writing these messages as much for myself, in order to get some clarity, as I am for the benefit of anyone else, but I hope that you find something for yourself and our work together in them. Some of these initial messages may be a little long, but I am sure that many weeks will just have a short thought or an inspirational quote.

When is Enough, Enough?

We all go through our days trying to do the best that we can. Yet, often it seems that something more is needed. Things don’t always go smoothly, systems need to be tuned up – just as cars need routine maintenance. What we did before was good, but what needs to change as we change [our clientele changes] and as systems change around us?

Sometimes I find myself asking the question: “Am I doing enough?”  “Is there something more that I could be doing, or should I be doing things differently?”  When I answer that there is more that I could or should be doing, I push harder, I try new things, I rush to get everything done so that I can get to the real work that needs doing. Sometimes in my work, I feel like I am so busy doing things that come up all day that I never have time to get “my” work done. I recently came across this quote below that I thought summed this up and I wonder if you relate to it the same way I do.

“As work turns into an ongoing series of emergencies, our efforts to achieve our major goals give way to damage control. Time is spent in stop-gap measures: putting out fires, plugging leaks, and filling cracks. There is no possibility for creative action or for enjoying the flow of productivity because all our resources go into catching up, repairing mistakes, and adjusting plans. The cycle is self-perpetuating: We do not have the time to make a good plan because our time is taken up dealing with the flaws in the old plan; we cannot clear up our communication because we are processing emotions stirred up by previous communications,” (Tarthang Tulku, Mastering Successful Work, pages 31-32).

Can you relate to those words?

How can we change the feeling that no matter how hard we work, it seems like it is not enough? (I am assuming that you relate to at least some part of this). As individuals, we can decide that enough is enough, that we aren’t putting in any more effort because we don’t feel that we are being recognized for our efforts, or that we feel we are already putting in too much. Sometimes this is necessary as a boundary or of recognizing our human limits, but we have to be careful that it is also not a sign of burnout, hopelessness [for ourselves, our jobs, or even the clients we work with], giving up, withdrawing, going through the motions, or even quitting.

There is another way when we reach this point, and that is to re-evaluate our expectations, our systems, and where we are putting our energy. This can be an evaluation as an individual, or it can be an evaluation of the system in which we, as a group of individuals, are working. As individuals, it takes time and space in order to be able to take a deep breath, to be able to see and understand our situation clearly, and in order to make decisions to change the way we are working on a day to day basis. This may mean looking at what really matters, what is important to us in our work, and what our needs are. Tony Schwartz and colleagues, in the book The Way We Are Working Isn’t Working, write that everyone has physical, emotional, mental, and spiritual needs, and that contrary to the way jobs have been set up in the past, that for an individual to be the happiest and most productive, these needs actually need to be addressed at work. This doesn’t mean that work is the only place in your life that you address these needs, but that in order to not only do your job, but also to feel replenished, valued, stimulated, and rewarded in your job, that we need these elements in our work. (Perhaps in another column, I’ll go into these four needs in more depth).

As individuals working together in a system, we need to look at how the system is structured to see if it makes our work easier or more difficult. We also need to look at other people around us, our friends and colleagues, to see if we can support them in getting their work done. I know that when I feel stressed, burnt out, over-worked, the last thing I want to do is look for more work, but in the business we are in – working with people to support them in their recovery and rehabilitation – the outcome for a client depends on all staff being able to do their jobs effectively. The other really important way that we, as individuals working in a system, can greatly affect our individual work, is by stepping back and looking at the structure of the system. We as individuals may not have created the system, but how we work every day maintains the system. Systems are full of complexity, however, and changing one aspect of a system often has unforeseen consequences, but this isn’t a reason not to evaluate and change systems when necessary, it is just a challenge of working with systems. The benefit of going through the change (which is hard work, just as any kind of therapy, recovery, or rehabilitation is hard work) is that putting in more energy, doing a little more, up front leads to our work becoming easier, more rewarding, more effective, and more productive down the road. In a way, changing a system is an investment of energy in the present that pays dividends in the future.

These are some questions that I have been asking myself, in my work, and in our work together:

How can we work better as multi-disciplinary teams, in such a way that we are better supporting our clients in their journey, and that we are happier in our work with clients and with our colleagues?

 

How can we feel more supported and valued in our daily work?

 

How can we keep our eye on the big picture, on what is really important for both ourselves and the clients we work with?

 

How can we change the system so that it feels more like we are all pulling in the same direction?

 

We have choices as individuals in deciding when we enough is enough. If things feel too hard; if it seems we work and work and work, and yet, it seems to have no effect; if we start to feel like it just isn’t worth it – that enough is enough – then we make have hard choices to make: we can do less, we can go through the motions, we can even quit, and quitting can take many forms, including just doing the bare minimum and going through the motions. However, I would like to offer another choice, and that is to re-evaluate our daily work as individuals and the functioning of the system that we are maintaining every day. If we change, the system changes; if we change the way the system functions, we can change the nature of our work every day.

I invite you to re-evaluate the structure of the system where we work:

How can we bring more of our natural caring and compassion into our work?

 

How can we nurture and support that part a client that wants to change and grow?

 

How can we make our work less stressful?


How can we improve our working relationships with our colleagues?

One way of doing this is a programme called “Releasing Time to Care,” developed in the National Health Service in the UK. We will most likely be using this as a framework for change where we work [this may happen in the future, but it is a complex, lengthy process and there are no immediate plans to implement this]. I will write more about this program in the future, but my understanding of it is that it can be applied in a way that is consistent with the recovery and rehabilitation model that we use with clients. I believe that we can only create an environment supportive of recovery and rehabilitation for clients if we are able to create the same environment for ourselves. Perhaps we can use this programme, as well as any other existing programmes, or even programmes that we create that are particular for our work, to support our daily work, so that we can feel energized by our work, valued for the work we do, intellectually stimulated and engaged in our work, and to feel that our work is purposeful and has profound meaning.

[Doesn’t it seem like I should have written something about when “enough is enough” with working with clients and we decide to move them on from BRC? I thought I wrote something on that, maybe we’ll have a part II of “When is enough enough?”]

Kindness

Before you know what kindness really is

you must lose things,

feel the future dissolve in a moment

like salt in a weakened broth.

What you hold in your hand,

what you counted on and carefully saved,

all this must go so you know

how desolate the landscape can be

between the regions of kindness.

How you ride and ride

thinking the bus will never stop,

the passengers eating maize and chicken

will stare out of the window forever.

Before you learn the tender gravity of kindness,

you must travel where the Indian in a white poncho

lies dead by the side of the road.

You must see how this could be you,

how he too was someone

who journeyed through the night with plans

and the simple breath that kept him alive.

Before you know kindness as the deepest thing inside,

you must know sorrow as the other deepest thing.

You must wake up with sorrow.

You must speak to it till your voice

Catches the thread of all sorrows

And you see the size of the cloth.

Then it is only kindness that makes sense anymore,

only kindness that ties your shoes

and sends you out into the day to mail letters and purchase bread,

only kindness that raises its head from the crowd of the world to say

It is I you have been looking for,

and then goes with you everywhere

like a shadow or a friend.

Naomi Shihab Nye

Amazon Review: The Creation of Faith, by Juan Mascaró

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“‘The Creation of Faith’ could be the title of a book based on the solid foundations of the best in religious, common philosophies and common spiritual sense,” (179-180).

Juan Mascaró was born Majorca, Spain and lived in India and England. He returned to Majorca after his death for burial. He is noted to have accomplished the unique feat of translating the Sanskrit and Pali languages that were not his own into the English language, which was also not his own. His translations and introductions to the Penguin Classics editions of The Upanishads, The Bhagavad Gita and The Dhammapada continue to stand as excellent introductions to Eastern wisdom for the English-speaking world. While he was an accomplished scholar, linguist, translator and academic, what I find most wonderful about Mascaró is that he was a poet, a mystic and a unifier of the spiritual wisdom of the world. It was after reading his introduction to The Upanishads (as exciting as the text itself) that I became interested in Mascaró, himself, and sought out this out of print book, The Creation of Faith.

In his introduction to The Upanishads, Mascaró wrote that “an Upanishad could even be composed in the present day: a spiritual Upanishad that would draw its life from the One source of religions and humanism and apply it to the needs of the modern world,” (Upanishads, 8). That is the best way to consider The Creation of Faith, as a modern Upanishad, the lifetime culmination of the wisdom and poetry of a man who immersed himself in the poetical and spiritual literature of the world (“Spiritual visions are poetry,” (111), he writes).

The Creation of Faith is a posthumous collection that was edited by William Radice, as Mascaró died before his final work could be published. The book consists of aphorisms and sayings, usually only a couple of lines in length. The aphorisms are not arranged in any particular order which gives the book the feel of collected notes. There are some repetitions of almost identical sayings. Personally, I think the book would have been stronger if it had been edited a little more and if the aphorisms were clustered around various themes, such as creation, duality, unity, love, poetry, etc., or if they were organized so that they were allowed to comment upon the related facets of various themes. I think the book may have been stronger if it followed Mascaró’s own advice to be a: “book of 100 pages, 300 words a page–30,000 words,” (178).

“I have two lives: my inner life with God, and my outer life with nature and men. How mysterious these two worlds are,” (169). The beauty of Mascaró’s writing is that he works with dualities and polarities without negating, but allows each duality to complement to form a greater unity. “There is inner observation and experiment and outer observation and experiment. From the first comes poetry and spiritual vision and all human values; from the second science and technology,” (31). Still, as a mystic, he sees the ultimate aim of study and scholarly work to be supporting self-knowledge and through self-knowledge, one reaches God. “The end must be clear: how can we find ourselves, the best in ourselves,” (25). “If we could know what we are, we would know what God is,” (111).

One of the most interesting aspects of Mascaró’s unification of spiritual and poetical world literature is his view of faith and spirituality as creations of the imagination. He does not mean that they are false or “made up,” but that they are products of the creative function of human imagination, a field of play that is beyond the limitations of words and materialism. A few quotes illustrate this. “Faith is creation,” (148). “Your soul is your own creation,” (152). “What is faith? It is an act of creation and vision. We create what we hope,” (171). He also provides an understanding of how to differentiate between higher creations that contain truth and lower constructions that do not. “Imagination is strong and creative. Fancy is weak and passive. A hallucination is a powerful fancy that overcomes reason. Imagination is creative and above reason. Fancy is passive and below reason. This is also the difference between faith and fanaticism. Faith is above reason. Fanaticism is below reason,” (129).

Mascaró also wrote a more scholarly work of unifying comparative religion called Lamps of Fire. This has proven to be difficult to find and is also out of print. The Creation of Faith is a great source of spiritual and poetical inspiration and I found that it nicely complements the 80-90 pages, in aggregate, of the introductions to The Upanishads, The Bhagavad Gita and The Dhammapada. Mascaró also appears to have solved the dilemma of knower and the known. “In love we know. In knowledge there is the knower and the known. In love both are one,” (58). His is a voice that is beyond cynicism and divisiveness. He gently brings together a pure heart and a keen mind in a playful and creative search for the unification of all things.

Thoughts from the Clinical Director

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I have decided that I will be posting my fortnightly “thoughts” column in the blog. I have been thinking about implementing this where I work for a year, now, but I have only just gotten the time and space to really do it. While some of the issues maybe particular to the specific workplace, I imagine that many of them are universal. Also, I end each column with a quotation of a poem. I have just written the 3rd installment, but I’ll post one of the old columns a week until we are caught up with the present time. Here is the column from one month ago….

Some Thoughts From the Clinical Director

I know everyone always works hard at Buchanan (Psychiatric) Rehabilitation Centre, but this has been a particularly tough week. I appreciate everyone’s work and concern for the Buchanan community in which clients engage in rehabilitation and staff strive to create an environment conducive to rehabilitation.

I had the experience with working with many services outside Buchanan this week, some of which were very supportive and others which were actively unsupportive. It made me realize that it makes a tremendous difference for the difficult work we do if we feel supported or unsupported.

We are going through a time of many transitions and I realize my decision to move back to the States is one of several big changes at Buchanan. I will keep everyone updated on where I am at in the process of that move. I just returned from leave and had a couple of job interviews, but I am not at the point of signing any contracts, so my time at Buchanan is still 90 days plus the time it takes for either Mary Pat or me to have a solid job. Mary Pat is now staying in Seattle and will be taking some licensure exams and looking for jobs there.

Our clients at Buchanan are often very difficult and challenging on the best of days and I do not see the referrals for new clients we are getting as being any easier than those currently at Buchanan. The work is going to continue to be difficult and challenging. We are going to have to continue to hold the hope for clients who come to Buchanan without hope. Hope is a precious commodity and we have to be very careful with how we care for our own hope. We also have to be careful about how we speak and act with clients because our words and actions can build hope or destroy hope. We also have to be careful with how we treat our colleagues at Buchanan and to strive to build hope and to make sure we are not endangering hope. This does not mean we always have to agree with each other. I saw a number of great examples where staff disagreed with each other this week, but still overcame those differences to work together for the best interest of clients.

I also went to a conference while I was in the States, it was called “Integrity in Health Care: The Courage to Lead in a Changing Landscape,” put on by The Center for Courage & Renewal. I thought a lot about hope while I was there, as well as of the shadow of hope, despair. We work with both of these on a daily basis in rehabilitation and we are no different than the clients in BRC who also struggle with these two fundamentals on a daily basis. What can be done to build and foster hope? That is the question I continue to return to during my time working in psychiatric rehabilitation. I generally return to human connection as the answer to that and during my remaining time at Buchanan this will continue to be my goal: increasing connection between staff and staff, clients and clients, and staff and clients. That can be a pretty lofty goal and sometimes it is nice to have something concrete to focus on, so my other goal I set for myself was to try to build more poetry into my life. I find that poetry can create a space to pause and reflect, to connect to my feelings and to connect to hope.

I have been meaning for some time to send out regular email of “Thoughts From the Clinical Director.” But, there is always so much important work that I do not get to everyday, this has been on the back burner. Perhaps it is not too late, even as I am in a leaving process from Buchanan to start this project. I will also share some of the poetry that we used at the conference. If it is of value to you and brings you hope, that is wonderful, if not, please feel free to disregard these periodic emails. Here is the first poem, it is a long one, but it was my favourite (Albuquerque is a city in the state of New Mexico):

 

Wandering Around an Albuquerque Airport Terminal

 

After learning my flight was detained 4 hours,

I heard the announcement:

If anyone in the vicinity of gate 4-A understands any Arabic,

Please come to the gate immediately.

 

Well — one pauses these days. Gate 4-A was my own gate, I went there.

An older woman in full traditional Palestinian dress ,

just like my grandma wore, was crumpled to the floor, wailing loudly,

Help, said the flight service person. Talk to her. What is her

problem? we told her the flight was going to be four hours late and she

did this.

 

I put my arm around her and spoke to her haltingly,

Shu dow-a, shu- biduck habibti, stani stani schway, min fadlick,

Sho bit se-wee?

 

The minute she heard any words she knew — however poorly used –

she stopped crying.

 

She thought our flight had been cancelled entirely.

She needed to be in El Paso for some major medical treatment the

following day. I said no, no, we’re fine, you’ll get there, just late.

 

Who is picking you up? Let’s call him and tell him.

We called her son and I spoke with him in English.

I told him I would stay with his mother till we got on the plane and

would ride next to her — southwest.

 

She talked to him. Then we called her other sons just for the fun of it.

 

Then we called my dad and he and she spoke for a while in Arabic and

found out of course they had ten shared friends.

 

Then I thought just for the heck of it why not call some Palestinian

poets I know and let them chat with her. This all took up about 2 hours.

 

She was laughing a lot by then. Telling about her life. Answering

questions.

 

She had pulled a sack of homemade mamool cookies — little powdered

sugar crumbly mounds stuffed with dates and nuts — out of her bag —

and was offering them to all the women at the gate.

 

To my amazement, not a single woman declined one. It was like a

Sacrament. The traveler from Argentina, the traveler from California,

The lovely woman from Laredo — we were all covered with the same

powdered sugar. And smiling. There is no better cookies.

 

And then the airline broke out the free beverages from huge coolers —

non-alcoholic — and the two little girls for our flight, one African

American, one Mexican American — ran around serving us all apple juice

and lemonade and they were covered with powdered sugar too.

 

And I noticed my new best friend — by now we were holding hands —

had a potted plant poking out of her bag, some medicinal thing,

 

With green furry leaves. Such an old country tradition. Always

carry a plant. Always stay rooted to somewhere.

 

And I looked around that gate of late and weary ones and thought,

This is the world I want to live in. The shared world.

 

Not a single person in this gate — once the crying of confusion stopped

— has seemed apprehensive about any other person.

 

They took the cookies. I wanted to hug all those other women too.

This can still happen anywhere.

 

Not everything is lost.

 

Naomi Shihab Nye

Guest Blog Post at the Center for Courage & Renewal Blog

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Please see my May 9th guest blog post at The Center for Courage & Renewal Blog (the full text can also be found below)

I wrote this after attending the 2nd Annual Health Care Institute:

Integrity in Health Care: The Courage to Lead in a Changing Landscape

The Center for Courage & Renewal promotes the work of Parker Palmer. I frequently cite Palmer’s work, particularly as it pertains to professional leadership in medicine, in my forthcoming book, Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice and the Culture of Medicine.

Another update is that I have been spending a lot of time working on my website, but you can’t tell it yet. All the new content should be posted there before too long.

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Recovering Hope, Poetry and Connection in Health Care

I recently attended the conference/retreat “Integrity in Health Care: The Courage to Lead in a Changing Landscape.” I arrived there in the usual state for me, tired, stressed and struggling to balance all of my clinical and administrative responsibilities with the rest of my life. I work as a psychiatrist and as Clinical Director at an inpatient/residential psychiatric rehabilitation program with a population of treatment-resistant clients and a staff group that is going through union action. I took on the job hoping that I could bring a holistic approach to foster recovery and rehabilitation for clients and well-being for the staff, but I am not sure how successful I have been with either the clients or the staff. Many days feel like a constant barrage of worries and concerns about clients, staff and a never-ending stream of emails.

What I found at the conference was not any easy answer or magic solution to my daily worries. What I did find was a chance to reflect on my own situation with a group of supportive facilitators and participants. Having this time and space allowed me to connect more deeply to myself as well as to connect with other health professionals struggling with similar demands. As a result of the conference I felt more hopeful, less alone and that I had more inner and outer resources to bring to my daily work. I think one of the most damaging aspects of our work in health care is the despair that comes from trying to do good work in systems that, directly or indirectly, seem to inhibit good work. We thus have systems in which everyone is working hard, yet no one feels good about the work that they are doing.

The conference was structured around Parker Palmer’s “Five Habits of the Heart,” from his book Healing the Heart of Democracy. These habits are: understanding we are all in this together; an appreciation of the value of “otherness;” the ability to hold tension in life-giving ways; a sense of personal voice and agency; and the capacity to create community. For me this boiled down to developing a sense of internal connection and cohesion while also developing connection to others and building community. This led me to reflect that if we can hold the inevitable tensions between individual and community in life-giving ways, the personal growth and well-being of the individual can contribute to the complexity and health of the community.

The idea of embracing tension rather than trying to eliminate it got me thinking of the tension in my own work and life. If I can shift my perspective toward daily stress and tension as a life-giving energy for work instead of as a drain and impediment to my work, perhaps I can more skillfully support the growth of a therapeutic community at the rehabilitation center where I work. The concept of a therapeutic community is that no one individual has responsibility for solving the problems that arise in the community, rather the work is done in open discussion between all members of the community. Palmer’s habits of the heart serve as an excellent guide for this kind of work by valuing the individual and the community and by seeing the tension as a source of life energy. To me, this was the most useful concept from the conference, that stress and tension can be re-framed and used for positive work.

This concept of holding tension between opposites, rather than trying to have one opposite (e.g. hope) overpower the other opposite (e.g. despair) allows for a complex and systemic approach to complex and systemic problems. The idea of tension being life-giving rather than something to get rid of reminds me of Swiss psychiatrist Carl Jung’s approach to the problem of opposites, that there is a “unifying third” that unites the opposites into a higher order of meaning. In this conference, we can look at integrity as the “unifying third” that comes from holding the reality of despair about contemporary health care and the need and fact of hope. In practice, integrity is generated from embracing the despair and the hope in contemporary health care.

Where does this hope come from? I found hope when I looked into the eyes of the facilitators and participants at the conference. I found it when I looked into myself. Hope is there, it is a living thing. It is just that there is also so much despair that it is easy to lose sight of hope. Hope is intrinsic to the very idea of health care. We all went into this field because we felt that something hopeful could be done in the world.

I’d like to return to this idea of tension being “life-giving.” The image that came to me was of the poles of a magnet. Electromagnetic lines of force emanate in complex and systemic ways around the negative and positive poles of the magnet. These electromagnetic fields create energy that can be used for work. Cancellation of either the negative or positive pole leads to a collapse of the energy and an inability to do work. To move from the metaphor back to our discussion of hope and despair, it is quite apparent that if despair eclipses hope no work can be done. (I will leave the opposite statement of what happens when hope eclipses despair to the metaphysicians, as this does not appear to be an immediate risk in health care.) If this metaphor holds, we can shift our attitudes toward the reality of despair and let go of our desire to eliminate it. Instead, we can view it as a powerful generator of energy and work when it is in a tension-filled relationship with hope.

We do not need any help to find sources of despair to feed this life-giving tension. However, we do need to periodically renew our sources of hope. Luckily these can be found when we pause in life and look within and look to others who are doing hopeful work. One great place to pause is at an “Integrity in Health Care” retreat.

This conference was not a passive, one-way exchange of information from the facilitators to the participants. We had ample time for personal reflection and small and large group work. The facilitators were compassionate and skillful in stimulating discussion and reflection to promote individual and group work. The other participants were inspirational in their personal honesty, their humanitarian drive to alleviate suffering and the creative ways that they were doing clinical and administrative work. I remember one small group where we discussed how we can facilitate individual and group reflection in busy health care environments. We spoke about mindfulness and poetry as ways to accomplish this. This discussion was very helpful for me and I take away a particular commitment to have more poetry in my life as I find it ignites a dimension in me that I often push on the back burner. As the poet and translator of sacred texts, Juan Mascaró, writes:

“The appreciation of a poem is an act of creation whereby we go towards the greater life that created the poem. An expansion of life.”

There is another tension in health care between the poetry of medicine and the science of medicine. We work in a time when the science (and the business) of medicine often obscure the poetic value in our work. Mascaró further writes that:

“There is inner observation and experiment and outer observation and experiment. From the first comes poetry and spiritual vision and all human values; from the second science and technology.”

What I take away from this conference is an enhanced ability to hold this tension between inner and outer observation and experiment, which allows human values and science to co-exist in the delivery of health care. Practically, this means I have a renewed sense of self-connection, a stronger sense of community and more hope from the work that others are doing in health care. With a handful of poems and a heart-full of hope, I return to my daily life and work.

 

 

 

Book Review: Bringing Human Values to Healthcare Reform

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I just published my first book review on Amazon! I will be periodically reviewing books that are relevant to the topics discussed in the Being Fully Human blog. The following review highlights Gerald Arbuckle’s Humanizing Healthcare Reforms, published in 2013.

Bringing Human Values to Healthcare Reform

Gerald Arbuckle writes from a truly international perspective, as a New Zealander, educated at Cambridge University in the UK, living in Sydney Australia, and having served as an organizational consultant in the US, Canada, and Australia. He trained as a social anthropologist and brings an understanding of how culture shapes values, beliefs and actions and he applies this knowledge to contextualize motivations in healthcare systems. His description of different models of healthcare illuminates the roots of the debates around healthcare reform. He describes the traditional (mainly indigenous) model of healthcare and the foundational model (based on equity, compassion, mercy and social justice) as both including a holistic approach, a sense of social and spiritual context and the valuing of interpersonal elements of relationship. In contrast, he describes the biomedical model and economic rationalist models as being focused on numbers and objectivity, and reducing therapeutic interactions to factors that can be counted, measured and economically valued. With an understanding of the different values of these different models, it can easily be seen why patients, doctors, healthcare professionals, third-party payors and government agencies have different priorities based upon the model of healthcare that they hold primary.

With the perspective gained through understanding that these models of care have different values and priorities, Arbuckle brings his understanding of the role of culture and how it can support or inhibit healthcare reform. He argues that the values of the foundational model of healthcare must be re-invigorated to counter-balance reforms based on biomedical or economic principles. In short, Arbuckle argues for including humanitarian values in discussions around healthcare cost and science.

I found Arbuckle’s conceptualizations quite useful in my own writing for my forthcoming book, “Re-humanizing Medicine.” He presents a well-reasoned argument from an anthropological perspective, which is not often heard in contemporary medicine. He champions human values amidst debates regarding cost and technology in medicine. His book provides a useful sociocultural context for the kinds of healthcare reform called for by doctors such as Robin Youngson, whose book, “Time to Care,” calls for greater compassion in healthcare. Arbuckle provides a great conceptual template as well as an inspirational call for leadership in healthcare that is collaborative and transformative.

What Do Holistic & Integrative Medicine Have to Do With the Quality Revolution in Healthcare?

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I recently went to the Asia Pacific Forum on Quality in Health Care, in Auckland. This event was put on by Ko Awatea and the Institute for Healthcare Improvement. What I found interesting was that in addition to issues around efficiency and evidence-based medicine, there was also a strong focus on patient and family involvement and collaborative care.

In some follow-up reading after the conference, I came across a short article by Swensen et al from the NEJM 362.5 (Feb 4, 2010) called “Cottage Industry to Postindustrial Care – The Revolution in Health Care Delivery.” This article argues that the concept of what  constitutes a “good doctor” is changing. Currently, to be a “good doctor” means “swimming upstream against the system, rather than relying confidently on it.” This reminds me of my writing on creating a holistic medical practice; the clinician relies on a standard of professionalism that is not always supported by the systems in which clinical work occurs. The article arrives at a contrast between the “good doctor” of the past and of the present.

“In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner.”

The components of emotional intelligence, systems focus, collaborative care, compassion, and patient-centered approach are hallmarks of holistic and integrative philosophies.

I was just reading a continuing education article called, “Improving Quality of Psychiatric Care: Aligning Research, Policy, and Practice,” by Kelli Harding and Harold Pincus (Focus, Spring 2011, Vol. IX, No. 2). The authors state that in our current health care system in the US, the “problems are so widespread that trying harder within the current system is not enough.  System-wide change is needed.” The authors mention the Institute of Medicine’s 10 Rules for Patient/Consumer Expectations of Their Health Care (adapted below from To Err is Human:  Building a Safer, Health System, 2000). Again there is a contrast between the old and the new:

Old Rules New Rules
1. Care based on visits Continuous Healing Relationships
2. “Do no harm” Safety is a system property
3. Professional rules greater than System Cooperation and Collaboration between clinicians and institutions
4. Decisions based on training and experience EB decisions without variance
5. Professional autonomy drives variability Individualization, customized care
6. Professionals control care Patient as source of control, shared decisions
7. Decisions based on training, experience Shared knowledge, free flow of information
8. Clinicians react to events Anticipation of needs
9. Secrecy is necessary Transparency in system performance
10. Cost reduction Value or continuous decrease in waste

Again, we can see that the focus of holistic and integrative medicine on individualized, patient-centered care, collaboration, preventative medicine, low-cost lifestyle modifications vs. high cost pharmaceutical interventions, and on the therapeutic value of a positive therapeutic relationship, all appear to have a prominent place in the new health care revolution, which the authors call a “paradigm shift.”

One area of creative tension between the new quality health care revolution and the holistic & integrative medicine revolution is the variable to time. We know that there is an association between shorter visits and malpractice claims, (Wendy Levinson et al., “Physician-Patient Communication: The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons.” JAMA, Vol 277, No. 7 (Feb 19, 1997):  553-559). We also know that it takes longer to support behavioral and lifestyle change than it does to write a prescription. We also know that time spent on preventative medicine saves time later as well as money, which is a quality issue. It may be that the quality revolution may make time for clinicians to spend more time with patients in certain circumstances in order to provide less expensive, safer, higher quality care. This is a long-term savings and is more efficient in the long-run, but in the short run it will cost more in clinician time spent with patients.

Creating a health care system that is quality-based, efficient, safe, and cost-effective is a challenging task and countries all around the world are struggling with this problem. It will be very interesting to see how the current health care revolution in quality, in the US, plays out and whether principles of holistic, integrative, and preventative medicine find a prominent place or whether efficiency and evidence-based pharmacological interventions take a more prominent place. During the last time of health care revolution, the Clinton plan in the 1980s, I was a medical student and had a chance to take an elective in health care policy and law. That revolution largely left the doctors out of the loop. Competition was supposed to solve the problem. Ten years later I was working at a multi-specialty group that went to a “eat what you kill” reimbursement policy. I understood the concept, but I couldn’t believe I was hearing this language used by the people in health care systems.

As a student, I remember reading that competition in health care is only cost-effective if there is a population of around 200,000. There then followed a map of the US showing all the regions with less than that population and I realized that system of reform would not work. This time around, it seems that many doctors are embracing the revolution and are more involved in the process of change. At least the language of compassion, collaboration, and continuous healing relationships has at least a linguistic place in the current revolution.

Authentic Leadership In Action

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Halifax, Nova Scotia, June 2012

I am sitting in the Vancouver airport, on my way back to Auckland.  I attended the ALIA summer leadership program last week. As part of taking on a new role of clinical director at the rehabilitation centre, I asked that I have some leadership training and this programme looked like a really good fit for my background in holistic medicine as well as the recovery philosophy of rehabilitation. ALIA grows out of the Shambhala tradition of mindfulness and meditation, but adds a philosophy of active engagement and participation in the world. Thus, there is a blending of mindfulness, creative arts, social activism, entrepreneurship, and creative, ethical business practices.

I was really impressed with the people teaching and attending the programme. In fact, it would be hard to say which was more valuable, the ideas or the people – if pressed, I would have to say the people.  Still, there were some good ideas about change in organizations. The sub-track that I choose was “How the World Is Changed,” which was based on Frances Westley and Barbara Zimmerman’s book, Getting to Maybe: How the World Is Changed. One of the most useful aspects of this model was looking at different stages of personal and organizational change and the traps that people can get stuck in. The shifting focus between individual, organization, community, and world was very similar to what I taught in my Being Fully Human class, so it was interesting to see how these holistic, interlocking dimensions were conceptualized in different ways at ALIA. I don’t have my notes right now, but perhaps I’ll put a few quotes and models in another entry of the blog at some point. I found it very energizing to meet a wide array of professionals from different fields, all very socially aware, idealistic, and committed to facilitating growth and change in the world. I only met one other doctor at the conference, and actually, I feel it is probably more fruitful for me to have had this leadership experience outside of a narrowly defined medical/psychiatric practice. I think it is 11:30 PM, Halifax time, where I started out this morning, but it is only 6:30 PM here in Vancouver. I am grateful to have had a few hours break here before getting back on another plane.

It was very interesting getting a Canadian perspective on social change. While there were people from New Zealand, Australia, and the States at the conference, the tone of the conference was very Canadian and I feel I have gotten a small feel for Canadian culture from this experience, which is a benefit I hadn’t counted on.

One aspect of the conference that I studied and appreciated was the challenge of bridging mindfulness, social activism, and business as the conference committee worked to create experiences that were personally transformative, as well as intellectually educational. My own work, for instance in my book, Creating a Holistic Medical Practice: A Guide for Transforming Your Self, Your Practice, and the Culture of Medicine, I try to take concepts that are more from the fringe and to bring these back into more mainstream culture. This is quite a challenge, because if too watered down, the energy is lost, but without some degree of translation toward the mean, readers would be lost. (By the way, I am still waiting to hear from a literary agent about whether they will pick up my book or not. I continue to check my email every day looking for their decision!)

All in all, I would say that ALIA is a positive force for change in the world, it is a great crucible out of which many good things will grow.