Tuesday, September 8, 2015

Narrative Concepts

The idea of narrative is becoming recognized as basic to understanding humans and culture.   Philosopher Alisdair MacIntyre writes, "[W]e all live out narratives in our lives" and "we understand our own lives in terms of the narratives that we live out."   (MacIntyre, 1981) . The default mode of the brain according to Washington University neuroscientist Raichle is to make up stories.   It is what we do easiest.   It is what burns the least amount of glucose.   It is, according to neuroscientists and artificial intelligence experts Shank and Abelson, the template for human memory.   We humans actually think more in terms of verbs than in nouns.   When we see something, we want a story about it.   We want to know what it does or what it can be used for.

What is narrative?   The shortest narrative consists of two action clauses and an orienting clause.   I like to tell a short story that one of our clients told.   She said, "One time I killed my boyfriend, but then he came back to live and tried to kill me.   That was when we were living in Georgia and I was dealing coke."   This short story tells so much.   It conveys the essence of a character, of a human being positioning herself to be seen in a certain light.   It contains values and emotions.   It conveys a richness of understanding far beyond its mere words.   It is a work of social art, complexly rich and detailed.

University of Auckland Professor Brian Boyd argues that our big brains arose to do story.   Brain evolved to do story because story worked.   Story worked because it is the most efficient way to store massive social information as illustrated above.    Each of us can, apparently, know about 500 other people.   The amount of information we need to negotiate relationships with these others is massive.   We retain it in the form of stories.  

Thus, narrative medicine means an understanding of health and disease for humans, that is grounded in the stories humans live out in their lives and the stories that we understand about our lives which give our lives meaning and purpose.   Whatever we do only makes sense in the context of being grounded in a story or two.   When you recognize that I have a belief, that belief only makes sense if I tell about the experiences that led me to form that belief.   This belief rests upon experiences that led to certain conclusions that are stored in a narrative template.

Probably you wonder why this excites me so much!   I would answer, "because it bridges my indigenous parts with my non-indigenous parts.   In growing up, I learned that everything that mattered was a story.   If my grandparents had something important to tell me, they would tell me a story.   I was expected to interpret the story, to make sense of the story and to grasp what they wanted me to know.   I learned that "all there is, is story".   In Lakota, our personhood is the synthesis or integration of a swarm of stories that surround us called the nagy.   These stories consist of all the stories that form us or that we have told or are enacting as we move about in the world.   This nagy also consists of all the tellers of those stories.   We are forever embedded in each other's nagy's.  
To bring that into the practice of medicine, it means that illness is embedded in the stories we are performing and that are performing us.   There is a biological story about how we are organisms who are born, live, wear out, and die.   Our lives are finite.   Within that finitude, however, are multiple social stories which interact with the "how long do I have to live story".   Another story tells us that some events within our lives appear to be random, meaning that I can't make sense of them.   I can't place them within a story.   However, if I find the stories that people are telling and that are told about them, often their illnesses are illuminated in some way.   The illnesses make more sense.  
David B. Morris of the University of Virginia, writes that narrative is above all a form of knowledge (Morris, 2005) .   In this view, narrative knowledge complements and differs from traditional "logicoscientific" knowledge (Charon, 2001) .   For Charon, narrative knowledge is less of a product than a tool.   It is "what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means."   Its identifiable properties -- beginnings, middles, endings, characters, conflicts, and turning points -- for Morris are more descriptive than definitive.
Narrative comes from the Latin word, narrare, which means "to tell" and refers to various forms of telling.   Philosopher Richard Kearney writes that, "[N]o matter how distinct in style, voice, or plot, every story shares the common function of someone telling something to someone about something" (Kearney, 2002) .   For Morris, these tellings include the gamut from fragments of discourse to ancient formulaic epic poems like the Iliad or The Odyssey to cryptic post-modern novels.   Other scholars go further than Charon to argue that all knowledge, even the conventional declarative knowledge of modern medicine is narrative because all knowledge is embedded in theory which is a story about how the world is supposed to work.   These stories have characters in the form of biological entities or molecules, they have plot in the sense of operations that take place upon these entities (enzymatic reactions, flows of ions, passage of molecules across membranes).   They have implicit values such as preserving the life of the organism.   Even mathematical proofs can be seen as narratives.   Some neuroscientists see human identity and the operation of human consciousness as narrative (Fireman, McVay, & Flanigan, 2003) .

Narrative is not strictly verbal.   It is visual, bodily, kinetic, musical, and mixtures of all these.   Choreographed dances are stories, such as American Spring as are musicals like Oklahoma.   For Morris, stories also hold the negative, what cannot be told, the gaps, silences, and what cannot be said.   Stories always contain a matrix of choices -- what is valued, what is marginalized, and what is excluded.   Within medicine, narrative reminds us that illness is always caught up in stories involving families, jobs, cultures, and meanings and is not limited to the simply biological rendering, which we call "the natural history of the disease".   Indeed, I suggest that illness is without natural history because it is always affected by human affairs -- by people's search for meaning and happiness, by the relationships in which they find themselves, and by the broader stories of culture.   Biology is not an island unaffected by the sea in which it swins.

Bibliography

Charon, R. (2001). Narrative Medicine: a model for empathy, reflection, profession, trust. JAMA, 286, 1897-1902.
Fireman, G. D., McVay, T. D., & Flanigan, O. J. (2003). Narrative and Consciousness: Literature, Psychology, and the Brain. Oxford: Oxford University Press.
Kearney, R. (2002). On Stories. New York City: Routledge.
MacIntyre, A. (1981). After Virtue: A Study in Moral Theory. South Bend, Indiana, U.S.A.: University of Notre Dame Press.
Morris, D. B. (2005). Success Stories: Narrative, Pain, and the Limits of Storylessness. In D. B. Carr, J. B. Loeser, & D. B. Morris, Narrative, Pain, and Suffering (Vol. 34, pp. 269-285). Seattle, Wash8ington, USA: Intertnational Association for the Study of Pain Press.

Single Payer Health

People's stories about health and disease determine their health behaviors.  I begin with an example of a patient whom I told 25 years ago that he had to take better care of himself and who just dropped dead of a heart attack in his 50's.  I wonder about how we help people change the story that they are living.  How do we help them change health destructive behaviors in a respectful way that honors the story they have brought?

Who should pay for health care?   If health care is a right and not a privilege and we should all contribute to each other's wellbeing, then how do we do that?   Taxation is the main means for governments to raise money, though I suspect that the current profits being generated in our capitalistic health care could go far to reducing the actual cost of health care if we no longer had shareholders and owners to please and CEO's of hospitals and health systems were public servants instead of capitalists.   The last time I checked the CEO of Health Care America was making an annual salary of 150 million dollars plus stock options and other perks.   We wouldn't tolerate salaries like that in the private sector.

I received enough comments related to single payer health systems on my last blog to make me want to write another essay on this topic (rather than respond to each comment one-by-one).
U.S. health care is the most expensive in the world by a factor of four and results in ratings that average about 27th in the developed world, all factors considered.

I think we should subsidize each other's health care because none of us are willing to sit and watch someone die in the waiting room because they haven't bought health insurance.   The Republicans argue that it is their right to eschew health insurance, but I'm sure few people would renounce health insurance if they could afford it.   Their argument is specious because few of them would stand by and let people die in the waiting room, either.   I'm quite sure some would, however, as they would see it as the will of God.   Like the Catholic Church in the Middle Ages, they would not want to interfere between God and man by helping a person to recover from God's punishment in the form of illness.   Once most of us agree that people can't just be allowed to die, then we have to pay for their care and some people's care is more expensive than others.   How are we to answer the question of people's own behavioral contributions to their ill health?   Should smokers pay a higher tax than non-smokers or is that factored into the tax on cigarettes?   Should people who regularly exercise pay a lower tax than sedentary people?   Should vegetarians be taxed at a lower rate than fast food aficionados?   The list is endless.   Figuring out the nuances of human behavior and how they affect health occupies the lives of endless epidemiology departments in public health schools around the world.   

The surprising downside (though maybe it's not) from some of single-payer health is that your health and your health related behaviors become my business.   I have an interest (because I pay for your illness) in controlling your behavior because "bad" behavior costs me money.   Therefore, matters that we have considered private are now public.   We must debate the cost of providing contraceptive care to which some Republicans object.   From a cost perspective, birth control is much less costly than children.   Only poor people could not afford birth control and the costs of not using it are then borne by all of us in the form of paying for the cost of their raising their children or our raising their children.   One Republican answer would be that many childless families (mostly white) are available to adopt children and should do so.

In the International Journal of Health Care Finance and Economics from 2009 (Volume 9, pages 1--24), in a paper on "Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's", A. H. G. M. Spithoven writes about how the U.S. spends most of all developed countries on health care. Nonetheless, the U.S. ranks relatively low on health care indicators. This paradox has been known for decades. The turning point comparing the U.S. and Canada was in 1972. Health expenditure as a percentage of GDP was higher in Canada than in the USA from 1960 until 1972. Since 1972 expenditure on health care has been higher in the U.S. than in Canada.   The U.S. and Canada are two countries that are sufficiently similar to make comparisons useful. The comparison of factors influencing health care expenditure in the U.S. and Canada in 2002 revealed that health care expenditure in the U.S. is higher than in Canada mainly due to administration costs, Baumol's cost disease and pharmaceutical prices. It was not inefficiency in providing health.

What is Baumol's cost disease?   Assuming that wages in low productivity sectors must keep up with wages in high productivity sectors, prices for labor intensive goods or services will rise relatively to prices of goods and services produced by the high productivity sectors (McPake et al. 2003).
Productivity in health care is difficult to improve because health care relies for a large part on a direct face to face relation between the health care worker and the patient.   For example, washing a patient needs time that cannot be reduced beyond a certain point. Health care, where a large part of cost comes from staff looking after patients, is a low productivity sector. Baumol's costs disease may be overstated because the "output" used in measuring productivity in health care fails to capture major improvements in quality or results. So, while the cost of medical spending shot up from 1960 to 2000, largely as a result of the development and wide-spread use of new medical techniques, the cost per quality-adjusted life year decreased.   Health indicators for both males and females, such as life expectancy at birth and infant mortality rates, reveal that the quality of health care did not improve in the U.S. in comparison to Canada in the 1960--2000 period (United Nations 2005 data).

Administration costs prove to be a significant variable to explain the difference in health care expenditure between the U.S. and Canada. America's health care is characterized by a fragmented payer system, while Canada has a single-payer system. The first has less economies of scale in administration than the latter because competition among providers of health care, on the one hand, and competition among insurers of health care on the other, result, among other things, in extra expenses in billing and administrative operations of health care providers who have to deal with 100s of payers and different rules and prices.

Overhead costs in Canada's single payer system are much lower than in the U.S. with 72 US$ health care administration expenditure per capita in Canada in 2002 and 367 US$ per capita in the U.S. For 1999: "In the United States, health care administration cost $294.3 billion, or $1,059 per capita [. . .] In Canada, health care administration cost $9.4 billion, or $307 per capita [. . .] After exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada". Using the same broad definition, this big difference is also reported by Himmelstein et al. (2003): "The U.S. wastes more on health care bureaucracy than it would cost to provide health care to all of the uninsured. Administrative expenses will consume at least $399.4 billion out of total health care expenditure of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286.0 billion in 2003, $6,940 for each of the 41.2million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage."

Another surprising public debate becomes for what should we pay?   In Canada, the National health system does not pay for dental care.   Apparently, teeth are superfluous.   In Holland, from where I am today returning, the government is about to decide that psychiatrists will no longer be paid for psychotherapy, only for prescribing medications for depression because medication is more cost-effective than psychotherapy and people can get cheaper psychotherapy from others.    I learned this at a Dutch hypnosis conference attended by a number of psychiatrists and family physicians.   Actually, the evidence in the literature does not support this contention.   A number of studies have shown that psychotherapy is more effective than medication or medication plus psychotherapy at 16 weeks.   For depression, a 2010 meta-analysis using the Freedom of Information Act to obtain all the clinical trials ever done on antidepressants (all must be reported to the FDA but not necessarily published) found no difference between medication and placebo.   A 2010 study compared behavioral activation (prescribing behaviors that cause the person to become more active) to cognitive-behavior therapy and to medication over 16 weeks.   Most antidepressant studies last 6 weeks, not long enough for psychotherapy to show its full effect.   

However, how much control should the payer have over how we physicians choose to treat people?   Typically, there are many equally good ways to treat a problem, though bureaucrats are not apt to notice this.   They wish the best way.   They wish a quick and easy answer.   And a bias exists!   Therapies that involve human interaction are always less trusted than technology.   We live in a world in which the bias is toward technology solving problems.   Payers for health care have an interest in what is provided just as do recipients of health care.   Where do the two intersect?   Her again, I would prefer Bernie Sanders (Senator, Vermont) solution of giving control of health care to local governmental units.   I think I would have a better chance of arguing my methods and why they should be compensated to a local board than to a faceless, nameless government agency.
Thus, in thinking about a single payer system, we must consider the politics of power.   Who decides what will be covered.   Who decides what we physicians are allowed to do and what we are not allowed to do.

Even as we consider who pays for health care, we must consider the kind of health care that we wish to have and how to insure that we get it. Today's health care relies extensively on technology which often fails to achieve its desired goals.   Some of us at the margin of health care want more human-oriented care.   We believe that health improves in the context of relationship and that physicians need to take the time to develop relationships with patients.   We need to have the time to develop the relationships to help people change the way they live and to change the way they see the world.   We need ways to provide care that allows us to spend time with patients and provide care that we and the patients believe will help.   The downside of single payer systems that are far removed from the doctor-patient relationship is that the control lies far from the relationship.   Bureaucrats don't necessarily even make evidence-based decisions, and evidence changes constantly.   Doctors and patients need some autonomy over what they decide to do to improve health.

Himmelstein, D. U., et al. (2003). Administrative waste in the U.S. health care system in 2003: The cost to the nation, the states and the district of Columbia, with state-specific estimates of potential savings. Cambridge MA: The Division of Social and Community Medicine, Department of Medicine, The Cambridge Hospital and Harvard Medical School; Washington, DC: The Public Citizen Health Research Group.

Sunday, February 22, 2015

Post Election Thoughts on ObamaCare

I haven't yet taken the opportunity this year to render my thoughts on U.S. health care and how it should be funded and implemented.    President Obama's plan for health care has come before the U.S. Supreme Court and its fate has already been decided.   We are waiting for the clerks of the Justices to write their opinions.   The Republicans maintain, in a strange twist of logic, that people demand the right not to buy health insurance.   With some exceptions of extremists, who would actually choose not to have health insurance if they could afford it?   The Republicans will next argue that people have the right to be poor and that we shouldn't take that right away from them!
My mother was leaning toward the Republican argument until I asked her what she would have me do if someone entered the emergency room in the midst of a potentially lethal heart attack without health insurance.   Should I save his life even if he doesn't have insurance? I asked.   Of course, she answered.   

"There's the rub," I responded.   "Once you believe that we as a society have the duty to save people's lives when they are having health crises for which they cannot pay, then we need a way to pay for it.   That's what we have now.   The nation's hospitals provide a somewhat dysfunctional local health insurance by virtue of laws preventing them from turning people away at the emergency room door.   Hospitals in New Hampshire have sued their state government because they are going broke from this policy arising from laws forcing them to provide care without any means of remuneration.   It's also important to remember that when those who have not had health insurance come to the emergency department, their bills are usually larger than those who have had care, because more has gone wrong.  
I found the interstate commerce debate confusing.   It seemed simple to me that we must care for whoever comes to our door regardless of where they live.   For example, our hospital in Brattleboro is the closest hospital for people who live in Hinsdale, New Hampshire.   If they have an emergency, the ambulance is going to bring them to Vermont regardless of any other concerns.   Our hospital is three minutes from downtown Hinsdale, while the closest New Hampshire hospital is 35 minutes away in Keene.   I'm not sure how well New Hampshire insurance pays our hospital, but I know that we do not accept New Hampshire Medicaid for psychiatric services since it pays $23 per hour visit (less for shorter visits).   That compares to Vermont Medicaid which pays $87 for a one hour visit.   State lines don't appear to exist when it comes to medical emergencies and hospitalizations; only for routine visits.   The New Hampshire to Vermont transfer works in reverse when we have really sick people in our hospital.   The closest major medical center is at Dartmouth University, which is in Lebanon, New Hampshire.   They send a helicopter to pick up our really sick people and bring them to the academic medical center for the advanced technology they have there.   Apparently state lines don't matter there either, for we don't send people the 260 km to Burlington, Vermont, to the University of Vermont medical center just because it's in-state.

The proposal which makes the most sense to me is that of Senator Bernie Sanders of Vermont, who believes that local regions should control their own health care budget.   I think this could work in Vermont because we could decide where the money is best used in accordance with our local values and practices.   We might choose to cover supplements and fish oil and not the most expensive drugs in the pharmacopeia.   We might add massage therapy for people with chronic pain and perhaps stop paying for anesthesia blocks since these do not appear to be better than placebo.   We might change every six months as data and preferences change, but we could do that.

I do think everyone needs health care coverage.   We need to know that we are covered in the event of illness or accident.   Someone must pay for this coverage.   It must come from health care insurance premiums paid by people or from tax funds also paid by people.   Either way, people must pay for health care, either through taxes or through premiums.   I would prefer taxes over premiums, but that is my personal feeling.   I would prefer a decentralized system in which each locality has a health authority which is populated by a community board of directors who determines how our portion of the health care tax is going to be spent in our community.   We could struggle together to make the hard decisions about allocation.   We could engage in the dialogic process as we do that.   It wouldn't be perfect, but no perfect decision making system exists.   Plus if we had the money locally, we would be forced to think locally about our neighbors and friends and not abstract concepts.
In my experience, what no one wants to address is the escalating costs of health care and why they are not going to stop rising.   Health care is only getting more expensive and will continue to become progressively, even exponentially, more expensive as time progresses.   New technology costs money and everyone wants more technology (seemingly).   New drugs cost more than old drugs, and everyone seemingly wants new drugs (though few new drugs work much better than old drugs).   When we invent a new test, we rarely stop performing the old test that the new test was meant to supplant.   Usually we do both tests.

The medicalization of life has generated tremendous costs for health care.   Ordinary misery has been elevated to a pathological condition.   Every ache or pain demands a label and a diagnosis.   In my role as family doctor, people bring to me a myriad of symptoms in search of diagnosis.   Most of these symptoms will defy diagnosis unless I can convince them that their symptoms are part of life.   Life involves aches and pains.   Life involves some element of suffering.   We get tense.   We get uncomfortable.   We forget how to relax.   We get anxious and experience the somatic symptoms of anxiety.   Our lifestyle leads us to pro-inflammatory conditions.   This irritates our joints, causes our immune system to produce pro-inflammatory cytokines which makes us feel flu-like, makes us feel depressed and more anxious, and promotes the development of other chronic medical conditions.   This pro-inflammatory syndrome is just being recognized and has no real pharmaceutical treatment.   Its solution is to sleep more, to exercise more, to eat an anti-inflammatory diet, to have more fun with other people, to stretch more, and the like.   So much of family medicine is about moving people in common sense directions to reduce inflammation which will improve their symptoms.   Laboratory studies don't really help me to do that, but are what patients often want.

Chronic pain represents another example from my area of practice.   Countless thousands of dollars are spent on X-rays, MRI's, and CT scans of the areas of pain.   They are really revealing.   Studies have shown that the findings of these studies rarely correlate with levels of pain.   They "hypnotize" an entire population of patients to believe that they are hopelessly immured in chronic pain with no hope of recovery, when that is not necessarily the case.   Often, the same simple measures will work wonders with chronic pain and cost very little.   Similarly, coaching people to lose weight and to exercise costs relatively little compared to the costs of being obese and not exercising, yet current health insurance does not cover these costs.   If we had local control over our health care dollars, we could make decisions about these types of matters on the local level and spend our money as we believe would benefit us best.   That's my recommendation for health care -- use tax dollars, cover everyone, give the money to the smallest local entity possible (village, township, shire, etc.), let the local entity decide how to spend it, and struggle with our unrealistic expectations of contemporary health care.

Friday, October 10, 2014

Problem-Based Learning

This week's blog is about teaching -- about my interest in problem-based learning (PBL) and interactive teaching.   My interaction with two students who do not like problem-based learning prompted me to write about this topic. 

First, everyone interested in this question, should, I think, view this resource:  http://americanradioworks.publicradio.org/features/tomorrows-college/lectures/
Under 'audio of the program' you can click on 'listen' and hear the whole program. 
Professor Tan of the Nanyang Technological University in Singapore [O. S. Tan, Problem-based learning innovation: Using problems to power learning in the 21st century. Singapore: Thomson Learning. 2003.] describes PBL as a learner-centered approach that positions students as central to the process. He lists some common characteristics of PBL approach:
We begin the learning process with a problem to be solved. 

The problem is similar to those that professionals or practitioners in the field encounter in the world and therefore has an unstructured feel to it. If it is a simulated problem, it is meant to be as authentic as possible. 

The problem calls for multiple perspectives. The use of multi-disciplinary knowledge is a key feature in many PBL curricula. PBL encourages solutions that take into consideration knowledge from various subjects and topics. 

Self-directed learning is primary. Thus, students assume the major responsibility for acquisition of information and knowledge. The tutor's role is as facilitator, consultant, resource person, and mentor.
Harnessing of a variety of knowledge sources are essential PBL processes. 

Learning is collaborative, communicative, and cooperative. Learners work together in small groups with high levels of interaction. 

The development of skills for how to ask questions and solve problems within the discipline is as important (if not more) than acquiring content knowledge needed for the solution of the problem.
Closure in the PBL process includes synthesis and integration of learning. 

PBL also concludes with an evaluation and review of learner's experience and learning process.
Besides the characteristics mentioned above, the PBL approach highlights the importance of the transfer of skills [Oon-Seng Tan, Problem-based Learning Approach to Human Computer Interaction, World Academy of Science, Engineering, and Technology 76: 462-465, 2011]. Learners are expected to transfer concepts learned previously to new problems although spontaneous transfer can be hard without practice or expertise. Transfer often fails because problem solvers fail to retrieve relevant information or skills that they need. Since in PBL the knowledge is encoded in real-life problems, students are more likely to retrieve the knowledge when faced with future problems. For example, during each unit in my class we consider a DSM diagnosis or clinical condition and the brain areas that might contribute to maintaining that condition.   There are too many diagnoses to fit into the seven units of the course.   The goal is to teach a method of approaching learning how the brain fits into behavior so that students can tackle any diagnosis using the methods and resources they learned and find the information they need to come to an understanding.   Of course, this works better, since the information will substantially change each year.   Memorizing facts from this year will not prepare students for next year. 

In medical education, we try to teach students a systematic way to approach new problems.   Given a disease you have never encountered before, what do you do?   We hope the student will know how to access the literature on that disease, will look for the theories of causation, transmission, risk factors, resiliency, treatments, and interactive effects.   Students will have practice in understanding that diseases that are categorized in any one specialty or organ system affect all organ systems and require knowledge from all disciplines.   The body is full inter-connected.   Similarly, our understanding of diseases changes daily and yesterday's facts are out of date already.

Can we teach classes that are not about memorization?  Can we bring problem-based, interactive learning to an online course? Problem-based learning because is evidence-based and performs so much better than more conventional methods.

The problem with problem-based, interactive learning is that the students have to participate and to interact with the teacher.  The argument for problem based learning is that the students learn up to 60% more material.  Plus, for students who engage in it, after the first shock of realizing that the class won't be memorization based, they report having a much better time and learning more.  Some students resist at first.  The American Radio Works program says, don't try this if you still need tenure(!).  But that is because it feels different.  A Harvard physicist in the program makes the point that it used to be that we couldn't easily get to the library to get information, so we needed to memorize.  Now there are endless online resources at the drop of a thumb, so we need to teach people how to find, translate, and use information. 

Interactive, problem-based learning formats do seem disorganized to students who are used to conventional education .  Conventional educational practice lays out of body of material to be mastered (learned, memorized, etc.) and then tests the students on their temporary retention of that material through quizzes and exams.  These newer approaches to teaching attempt to engage the student in a discipline through interacting with it and learning its questions and challenges and where to find the relevant information.  There's not necessarily a body of knowledge to retain but rather a sense for how to orient oneself and find the information when needed again.  I can see how that could seem disorganized to someone who is used to conventional practices.  However, the literature suggests that the kinds of students who do best with these newer methods are just the ones who flounder at conventional education .  Many of the students who sail through college and graduate school without interruption are found to do well regardless of method used.

I'd like to see us change the culture of education .  The culture seems to resist frequent contact and interactive learning in favor of a kind of hierarchical isolation from the instructor.   This can become especially true in the on-line environment, which doesn't have to necessarily mean low contact with faculty.  I'd like to see students involved from the beginning in shaping the course the way they'd like it to go.  Interactive PBL requires student presence.  The University of Minnesota, Rochester, which is a health sciences campus that feeds the Mayo Clinic, entirely uses this approach and doesn't even have a lecture podium.

I have a way to go to get to where I'd like to be for the online environment.  For example, in one of my on-line classes, I still did two fairly conventional lectures each week with powerpoints though I encourage discussion.  Because I don't know who (if anyone) will attend, I need material upon which to fall back.  I also make my slides available as study guides/resources.  I'm still not generating the level of discussion I would like, so I have to be prepared to lecture.  I usually lecture for one hour and then have a half hour of discussion. 

Here is a summary of what students don't like about this style of education (the full article from McMaster's University is available at http://www.personal.psu.edu/wxh139/PBL.htm):

Students' Readiness for Problem-based learning:
In PBL, students are not passive information receivers any more. They are expected to more actively engage in their learning process. Therefore, you should take into accounts of students' motivation, background and learning habits before you think about employing PBL into the classroom. Since the PBL approach put the responsibility of learning into the hands of students, students who are used to the structured and sequenced information presentation from the instructor may fail to make progress in learning and resent the self-learning challenge. 

Research on students' perception of PBL has reported that students' concerns about PBL include the unfamiliarity of PBL formats, dramatic differences between competitive and collaborative learning, demands on time and self learning, and ambiguous learning situations with direct instruction. Kingsland (1996), in his evaluative study of the architecture program at the University of Newcastle, reports students' reactions to the time issue in the problem-based learning: 

"Architecture 1 students maintain Reflective Design Journals to aid in the development of design and critical analysis skills. Comments in these journals highlight times of high stress due either to the accumulation of assignment or to time management problems." 

MacPherson-Coy, Sullivan and Story (2000) listed students' response to the question " What did you like least about the PBL program?"; stress over lack of time to complete everything and stress over getting familiarized with the PBL format are on the top of the list. 

In order to resolve students' resistance to PBL, enhancing students understanding of and positive attitude toward PBL process can help prepare students to face the challenges of PBL. If instructors perceive that students will have difficulties in self-directed learning, they may either provide more support during the process or accommodate students' different learning styles by balancing the learning activities via lectures, group discussions, and self-directed inquiry. 

Also, PBL relies on collaboration between students to bring in different perspectives and knowledge bases on problem solving. However, students' prior experience and skills in teamwork may either facilitate or impede students' learning in PBL. Therefore, the instructor should be open to any questions and concerns about the collaborative process. Nelson (1999) suggested to give an overview of the basic ideas and ideas about the collaborative problem solving process helping students understand what they will be engaged in and why.


 

Tuesday, May 27, 2014

Youth need to be heroes now more than ever!

Today, I had to arise at 5 am in order to run and be on time to Mission Australia's Youth Forum.   We had a long taxi ride across Sydney to a beautiful, green-grassed, lake present, conference center, with crazy birds with long thin beaks, who made shrieks from time to time.   The atmosphere was absolutely bucolic and the conference center modern and lovely.

Norma Ingram gave the welcome to country.   We learned that she had earned her Master's degree In Education at Harvard University and had visited Vermont during her year in the USA.   Norma formally welcomed everyone to her ancestral lands after which Rocky and I sang a song for her as the opening to our presentation.   Rocky gracefully allowed me to give the initial 45 minute talk and then we split the room into two groups for an hour break-out session.   I showed my usual slides to introduce my mother's people and land and then my father's people and land.   I began with the idea that youth appear to need to be heroic, now more than ever.   In a 1959 paper entitled The Adolescent Hero: A Trend by James William Johnson In Modern Fiction Twentieth Century Literature: A Scholarly And Critical Journal (Volume 5, Number 1 April, 1959), we learn that the literature of adolescent heroes began to dramatically increase in 1929 and continued to grow through 1959, and, I believe has continued ever since.   Adolescents, especially males, appear to need to feel heroic in some way.   They are saturated with stories extolling heroes and demanding that they be one.   Sometimes they choose pathways to heroism that adults find objectionable.   For example, joining a gang is a pathway to heroism, though often lethal.   I talked about how traditional cultures have historically had procedures for declaring a young person to be an adult and ways for them to be heroic.   I talked about using culture to create other opportunities for heroism, including the challenge of the sweat lodge, of sun dance, of vision quest, and the opportunities to feel heroic.   I talked about a pediatrician I know who prepares Lakota children for a swim from Alcatraz to San Francisco across the Bay -- the journey that was believed impossible when Alcatraz was founded.   We talked about the horseback rides across the reservation that Patrick Chief Eagle provides on the Pine Ridge Reservation.   A man in the audience mentioned that he was working with Maori youth to make and sail canoes in the traditional way.   I mentioned the programs for Native Hawai'ian youth to make and sail canoes between islands.   We just have to find ways to make what we adults consider to be wholesome and healthy seem more desirable and heroic than their alternatives like gang membership or the culture of drugs.   I argued that much of dysfunctional adolescent behavior can be understood as an attempt to save face when the attempt to be heroic or become a hero has gone awry.   I defined narrative units as I did on Day 3 for the Hearing Voices Conference and talked about the importance of creating positive story.   My slides are available to anyone who wants to email me at Email address removed .

After lunch, we heard Leonie Green, the Director of New South Wales Community Services talk about the recently launched Mental Health Strategies for Mission Australia.   She said that their previous strategy did not fully identify the need they had.   She talked about their biggest barrier being how to refer clients into clinical mental health services.   When people rang the mental health outreach services, they didn't get responses because they didn't have the language down that mental health used.   They don't actually see themselves as a provider of mental health support services in the broadest sense, though the majority of their clients presented with mental health issues.   She said, if you look at the social determinants of mental health, they are homelessness, poverty, unemployment, family breakdown, and the like, so it should be quite natural that their clients should present with mental distress.   She said that mental health should be everyone's business.   When people stop being homeless, poor, and unemployed, often their mental health improves.

Six months ago, they started drug and alcohol services which have been rapidly expanding. They call this a community of practice for youth services.   Everyone involved with youth in that area comes to the table to interact around managing these youth with drug and alcohol problems.

Here are some of the highlights of their current strategy:
1)       Replace the term mental illness with the terms "mental distress" and/or "loss of mental wellbeing", as these terms were less stigmatizing and recognize the diversity of experience that bring people into contact with mental health services.
2)       Services should transition from inpatient hospital to integrated community services.
3)       Social determinants of mental health need to be more widely recognized and addressed.
4)       Adopt a Recovery Approach to underpin service delivery.
5)       Establish a Consumer and Carer Reference Group to include the voices of people of lived experience of mental distress and loss of wellbeing and their carers in the planning, design, delivery, and evaluation of services.

We learned that aboriginal people have high rates of mental illness and loss of mental wellbeing in their communities.   Rates of suicide and self-harm are 2 to 5 times higher for aboriginal people than other Australians (http://www.aihw.gov.au/indigenous-Australians).   The New South Wales Social and Emotional Wellbeing Policy (2006-2010) states that the tragic state of Aboriginal mental health is due to a "" complex inter-relationship of individual, historical, social, cultural, economic, and environmental factors (and that) collective distress and trauma exist as underlying stressors to aboriginal life." (New South Wales Department of Health, 2007.

We learned that Mission Australia is at the forefront of responding to the social and emotional wellbeing needs of aboriginal people, especially in rural and remote portions of NSW.   At their Mac River Youth Drug and Alcohol Rehabilitation Service in Dubbo (where Sally made her documentary on elders sharing stories with youth) every referral except one had been an aboriginal youth.   They anticipate providing increasing services to aboriginal persons released from prisons due to their high levels of mental distress.

Next we heard about the Recovery Model, which was also prominent at the Hearing Voices conference from Day 3 and Day 4 of this journey.   It emerged from the consumer/survivor movement following the de-institutionalization era of the 1970's and 1980's.   They define recovery "as a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles.   It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness.   Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness." (Anthony, W.A. (1993). Recovering from mental illness: The guiding vision of the mental health service system in the 1990's. Psychosocial Rehabilitation Journal, 24(2), 159-168.).   The U.S. does not subscribe to the Recovery Model so much but is steeped in the biomedical model.   My sense of Australia is that its physicians are also steeped in the biomedical model with a large disconnect between psychiatrists and other mental health professionals.

Mission Australia (NSW Mental Health Strategy 2012) wrote that "Recovery is not dependent on professional intervention and can and does occur without it. Recovery does not mean an absence of symptoms. Rather when achieved, it allows people to live meaningful lives regardless of any unremitting symptoms and periods of relapses". [R]ecovery is not a linear process"."

Next Dr. Ramesh Manocha, Senior Lecturer at the Sydney University Psychiatry Department and Founder of Generation Next (you can google him) spoke about meditation -- what it is and what it's not.   He's planning a study with Mission Australia to teach kids at risk how to meditate.   He presented a study of 40 minutes of meditation instruction twice weekly for one term who experienced improved benefits in grades and study habits.   He found that the people who were experiencing mental silence several times per day or more had the highest mental health scores.   People who experience mental stillness less than once per month had the lowest mental health scores.   He reported taking 14 women with hot flashes who were perimenopausal for 8 weeks twice weekly meditation instruction.   They were to meditate twice per day.   They found a 70 to 80% improvement in symptoms using meditation at the end of 8 weeks.   The majority of women maintained a benefit at 16 weeks except for one woman who stopped meditating.

At this point we had to leave the conference for our trip back to Melbourne and the final day of our Australian Cultural Exchange Adventure.

Monday, April 22, 2013

Day 12 of the Australian Journey 2012

Today I was more accepting of my lack of status as a pedestrian while I took my morning run.   To show the difference in perception, I mentioned to my Australian hosts that the law of the sea gives the right of way to the slowest vessel.   They were aghast.   How could that be possible?!?   The right of way should go to the fastest vessel, and that's how they drive on land also.

Today we did another inipi ceremony (a.k.a., sweat lodge) for our Mission Australia hosts.   Two locals joined us who had spent substantial time on the Pine Ridge Agency in South Dakota and knew many songs.   They tended fire for us and carried stones, and the lodge sat on land they leased to be able to run regular ceremonies.   We really appreciated their help and to know about the Lakota-Sydney connection in which Lakota elders regularly came to teach in Sydney and Sydney-ites went to visit the elders in South Dakota.

Another thought came to me today -- culture exchange is different from cultural tourism.   In cultural exchange, each culture has something to offer the other.   In our coming here to do culture exchange, we gave as much as we received.   The local aboriginal people enjoyed participating in our culture as much as we enjoyed participating in theirs.   To my surprise, now, I know more about local aboriginal practices that many Australian I meet.   Like people in the States, they look for the exotic (our current spirituality du jour is Peruvian and ayahuasca) and ignore the richness of practice happening all around them.

The remainder of the day focused on Mission Australia with a fitting ending of listening to our host, Phil, play a mean lead guitar at open mike night at a local restaurant/bar in Manly.   The humor began when we heard it referred to as a Manly gig. Therefore what I want to discuss next is what I learned about the excellent work that they do.

First we heard about the Catalyst-Clemente program, which offers a model of how university education can become accessible to disadvantaged people.   It uses higher education in the humanities, delivered in a community setting, to engage with people who are disadvantaged and would not otherwise receive this education.   It involves a partnership between a university, community organizations, and a range of external supporters.   The subjects taught are fully accredited by the university and are in areas such as history, literature, ethics, and art.   The basic requirements for participants are a willingness to learn, a willingness to commit to a 12 week program, a literacy level that is sufficient to read a newspaper, and some stability in their lives.

To my surprise the origins of this program lie in the USA where New York journalist and social commentator, Earl Shorris, began the Clemente program in 1997.   Its philosophy is that tertiary-level education in the humanities can assist socially disadvantaged/marginalized people to think about and reflect upon the world in which they live.   In turn, this intellectual engagement can promote a broader re-engagement with society, activity with other people at every level, and assist them to exit from the cycle of poverty.   (See Earl Shorris, Riches for the Poor: the Clemente Course in the Humanities,published in 2000 by W.W. Norton and Co. in New York City).   "Students learn to view themselves in terms of their intellectual and personal capacities, to see themselves not as victims, but as agents.   Mission Australia is running this program in conjunction with Australia Catholic University.   I thought, this is something my institution, Union Institute & University, could consider doing in partnership with other community agencies.

This program is being researched around the world.   Mission Australia conducted a pilot student into the impact of the program on re-engaging homeless people in inner city Sydney.   Results were positive, showing increased student self-esteem and autonomy (Yashin-Shaw, I., Howard, P., & Butcher, J. (2005).   Educating disaffected adult learners: Re-engaging the homeless through tertiary level humanities studies in Vocational Learning: Transitions, interrelationships, partners, and sustainable futures. Proceedings of the 13thAnnual International Conference on Post-Compulsory Education and Training, Brisbane, Australian Academic Press).   Following this pilot study, Mission Australia, the St. Vincent de Paul Society, and the Australian Catholic University (ACU National) carried out a second phase of research into the benefits of this program.   They ran three Catalyst-Clemente courses (as they named them) simultaneously in Sydney and in Brisbane.   An art history course was taught at Mission Australia Centre including a visit to the New South Wales Art Gallery and a couple walking tours of the city.   A practical art class was taught in Brisbane including an exhibition with other ACU National students of the artwork created during the course.   A literature and drama course was taught at Vincentian Villege in Sydney, including students performing a play and attending a production of Shakespear's The Tempest at the Sydney Opera House with other ACU National students.   Over half of the students successfully completed the courses, which was extraordinary given their disadvantaged backgrounds.   The students' descriptions of how the course changed their lives are moving and can be found on the Mission Australia website athttp://www.missionaustralia.com.au and in their publication, Enhancing participation: New possibilities for disadvantaged Australians.   The work was especially interesting to us in relation to a small pilot project we did of teaching homeless people with HIV/AIDS (and mental health issues and substance use problems) in New York City how to give Reiki energy healing treatments to one another.   The effect was one of empowerment and building a sense of agency -- pride that they had something to offer other people.   Even staff members at the facility where we encountered them would ask some of them for a Reiki session.   We published this study in the Permanente Journal in 2011.   Encountering this program at Mission Australia has given me more ideas for how to empower our population in Vermont, some of whom are homeless, and many of whom suffer chronically from any number of problems.   (I've noticed that people who have psychological suffering invariably have "physical" suffering.   The division of psychology and body is artificial and for academic purposes but perhaps compromises care.   Almost all of our patients with what we call "complicated minds", because they like the term and don't feel it is pejorative, also have chronic back pain, chronic neck pain, neuropathic pain.   Some have diabetes.   Many have asthma.   Some have chronic obstructive pulmonary disease.   Almost all have difficulty sleeping, and many have arthritis, hypertension, heart disease, and more.   The list is endless.   Because we do both medicine and psychiatry, we are addressing the whole person and that's a lot to handle.   I thought how wonderful it would be if our population had a Catalyst-Clemente Program.   Currently they can't access the courses offered through Community College of Vermont because the tuition is beyond their means (about $500 per three credit course).   Also, paralleling the findings of Mission Australia, going to CCV is not necessarily friendly for them.   They're not familiar or comfortable with a school environment.   Classes are often larger than 8 to 15 people.   They don't necessarily have a case manager who can support their non-educational needs to whom learning partners and the course instructors can turn for support.   They don't have IT support or access to computers or knowledge about how to use computers.   Mission Australia provided all this in an integrated, delivery environment in which the students felt comfortable.   This is what I do not see us doing in Vermont, at least, not yet.


The other project about which we heard much was "The Michael Project", conducted by Mission Australia in collaboration with Murdoch University.   "The Michael Project combines homeless and accommodation services, assertive case management, and eleven specialist allied health and support services."   I is a three year, private donor funded project, working with homeless men in the Sydney area.   It provides homeless/accommodation services, ranging from mobile, street-based outreach, through to emergency, short-term, and medium-term accommodation.   Case management involved frequent contact and integrated support.   The specialists involved included dentist, podiatrist, psychologist, drug and alcohol counselor, recreation therapist, barber, occupational therapist, reading and math teacher, computer consultant, and two street-based aboriginal health outreach workers.    The Michael Project reduced the percent of "rough sleepers" (no shelter) from 27.4% to 3.3%.   The percent of people accommodated rose from 27.8% to 93.9%.   The percent in temporary shelter (caravan, boarding house, etc.) felt from 20.7% to 0.8%.   The percent in hospital or prison fell from 15.2% to 0.8%.   This had to be cost-effective!   They are well on their way to publishing their Wave 2 results, which I hope to receive soon.

As part of the Michael Project, homeless people were surveyed to learn more about their situation and how they came to be that way.   The researchers found that sleeping rough is common with the mean length ranging from 1.5 years to 4 years.   The prevalence of mental health conditions and substance use was at least 20 times higher than those of the overall Australian male population.   To their surprise, half of the people had held a full-time job in the last 2 years.   Of course, poverty was overwhelming.   A majority had children, but lacked supportive family members and friends, which contributed to their social isolation, as did their lack of paid work, money, access to transportation, and poor health.   Quality of life was low compared to overall Australians, particularly in terms of social relationships and living environment.   High levels of health service use and contact with the criminal justice system were found.   Ninety-five percent of the participants had experienced one or more traumatic events, which is not surprising considering that people who are diagnosed with psychosis are about 50 times more likely to have experienced traumatic events than the general population (see my blog about the Hearing Voices conference on Day 3 and 4).   I'll also be very interested to read about the cost-effectiveness study that is being conducted.

That completed our day.   Tomorrow we will interact with Child and Youth Initiative (CYI workers) about how increasing narrative competence can improve their work with youth.   Particularly, I believe almost every adolescent male in today's culture is looking for some type of heroic role to perform.   Everyone wants to be heroic and to be seen as a hero.   But, how?   Sometimes anti-heroes are easier to perform than socially acceptable heroes.   And, sometimes, adolescents notion of hero does not match that of adults.   More about that tomorrow.

Day 11 of the Australian Journey 2012

Today we interacted with Mission Australia in Sydney, but first, I awoke early and went running down Manly Rd. through 3 km of forest.   A sign read, "Wildlife", but I only saw road kill -- a possum, a snake, and a rat.   Australian drivers (Melbourne, Sydney, and Gippsland is my sample space) never slow down, not for pedestrians, not for other cars, not for bicycles, not for wildlife.   I discovered that Sydney bicyclists at 6 am on a Saturday morning were just as ruthless.   Well decked with racing togs, they aimed straight at me and gave no ground along the shoulder of the road.   I had to step aside into the bush or they would have mowed me down.   Imagine two headlights coming straight at you on the shoulder of the road.   What's that care doing, driving on the shoulder?   Is it some crazy man trying to kill me?   No, as it gets closer, I realize it's two bicycles riding parallel with no intention of sharing the shoulder of the road with me despite catching me in their high beam headlights.   Luckily, unlike the wildlife, I survived Manly Road, though perhaps more ignobly than manly, and returned to the house where we were staying in time to shower and pile into the Subaru SUV to make the journey into downtown.

Mission Australia was amazing!   I can't begin to say enough about their services and commitment to the homeless and the poor!   They provide programming and shelter for homeless adolescents and adults.   People come for an initial period of 3 months.   Some then transition to other spaces and others continue to stay.   Detox used to take place in the basement, but it has moved to another building.   Adolescents and actually anyone who lives in the vicinity can take advantage of the many programs offered.   They can access a center to help them find employment.   They can get dental and medical care free.   They can use the computers and the internet.   They can take yoga.   They can access a number of offerings about the practicalities of life including managing a bank account, playing chess, taking martial arts, writing a resume, and more.   They can take college courses through Australia Catholic University's Catalyst Program.   On the bulletin board were notices for Intro to Sociology, Intro to Art, Drawing 1, Graphics Art, and more.   We entered the building through the art studio which was massive and full of amazing work.   I learned that people entered the building as prostitutes and emerged as artists!   Their work lined the walls and was deeply moving, highly artistic, and sometimes disturbing.   From the art studio, we entered a recording studio where clients could take a course that culminated in their making a CD of their own music.   A number of CD's were available for us to take.   They were amazingly good!   This studio was a project of our hostess's husband, Phil, who is both a musician and a psychologist.   He serenaded us the previous evening with his Fender Stratocaster guitar, apparently the same model favored by the legendary blues musician, B.B. King.   The amount of program offerings and courses was overwhelming.   I have never seen such a comprehensive, integrated program in North America.
Mission Australia serves many aboriginal people in a culturally sensitive manner.   Another of our hostesses, Sally de Beche, now affiliated with Life Is"Foundation in Melbourne, used to work with Mission Australia in Sydney.   As part of her work she made a DVD documentary, Unsung Heroes, the stories of aboriginal elders in Dubbo, New South Wales, sharing their stories with young indigenous people.   The DVD focuses on lost traditions, cultures, and experiences for young people.   One of the elders didn't live in a house until he was 10 years old and didn't have electricity.   He was concerned about bringing his friends home because he lived in a tent.   One of the young aboriginal people commented that he didn't even know how to go camping.   It's about sharing verbal stories which the elders were forbidden to pass to the young people.   Hence, a lot of young people are just learning these stories which are not written down.   These stories explain for young people their feelings of being lost or disconnected from culture.   This reconnects them with the source of their traditions.   Sally told us how impressed she was with the resilience of these people.

We began our workshop at Mission Australia with a talking circle in which we heard people's wishes and concerns and what they wanted to learn from us.   Their focus was to learn new ways for dealing with psychological suffering.   Sally talked about using mindfulness and inner child work.   She mentioned a grief and spirituality group that she and Tony Gee conducted at Life Is"Foundation.   Everyone in that group had lost a child, either to suicide, accident, or disease.   Using a talking circle format, people told their stories to each other.   Paradoxically, this became an uplifting experience in which they connected with the link to "expansive reality".    Another participant wanted to learn about the use of ceremony with clients.   A third wanted to explore how to release ancestral pain.   I gave a short lecture about the post-modern, narrative paradigm, which is remarkably similar to indigenous thought.   I also let people know, as I have done everywhere we have gone during these two weeks, about the Narrative Medicine and Psychology Program we are starting at Union Institute & University in the USA where I teach.   I talked about how radical it is to see everything as a story, to move past the idea that some explanations (stories) are more privileged than others or that there is a "truth" out there waiting to be discovered.   In this paradigm, I said, we realize that we are forever uncertain about the nature of things.   We invent the best stories we can and revise them as we go.   In essence, this is Karl Popper's philosophy of science.   We make up stories to explain the actions of the world around us.   Some of this stories work better than others.

I talked about the Kaua'I Longitudinal Study from Hawai'i, started in 1950, in which young children, living in the most abject circumstances were followed to assess what would happen to them.   The study continues today, over 60 years later.   In the 1950's, the prediction was that everyone would be scarred for life and would have a terrible outcome.   Actually, this happened only to one-third of the children.   Another third had perfectly normal lives, and the final third excelled far beyond anyone's expectations and beyond the middle class children of the area.   Mentoring made a huge difference, sometimes even only briefly.   My point was that trauma is not always indelible or irreversible.   Today, trauma is our new devil.   "Trauma made me do it," is the contemporary story.   My point was that all truth claims are suspect and subject to refutation.   What matters is that I enter into the story of the client.   My story actually isn't very important and pales in comparison to the story of the client.   When I listen carefully to the client's story and enter into it, I can move it along toward healing, toward reduction of suffering.
I also talked about how Native North American culture is very present-centered.   The Lakota language does not have past or future tenses.   The indication that something is past or future is accomplished by a particle at the end of the sentence, almost as an afterthought.   Most of our pain happens when we live in the past or the future.   Focusing on the present reduces our pain dramatically for the present moment is usually pretty comfortable.   Unfortunately, the default nature of our brain is make stories.   That's good and bad.   We use our large brains to generate simulations of what people might do in various social situations given various behaviors we could perform.   That's really useful for being social animals but we can get carried away.   We can make story so much in the past or the future that we drive ourselves crazy.   Making story uses the least amount of glucose of any activity we do.   To meditate requires much more glucose.   Meditation is an effort.   We have to work to stop spinning yarns.   Though the effort is worthwhile.   When we stop making story and quiet our minds, we realize life is good in this moment.

I also talked about the similarity of Morita thought to Native American culture.   Morita viewed emotions as weather.   If you don't like what you are feeling, he wrote, wait five minutes.   Definitely, he said, if you are angry at someone and want to take revenge, wait three days.   You will feel differently.  

I spoke about the Lakota language having no word for "I".   There are me's, but no I's.   The implication is that we are defined by the group rather than ourselves.   As I have said before in these blogs, Lakota has no self.   Being is composed of the nagi (all the stories that shape us and the tellers of those stories), the s'icun (our presence or what we feel when a person leaves the room or when we enter the home of someone who is not there), the "breath of life" which makes the air go in and out and the blood go round and round, and finally, the spark of the Divine which lives within us.   "I" is a story we construct to fit the social situation in which we find ourselves.   We select from our many "me's" to create an "I" which changes as the social situation changes or as we evaluate the created "I" to see if it got what we wanted.   Hermans and Baumberg call this positioning.

I talked about North American aboriginal thought seeing illness as more of a teacher and biomedicine seeing it more as an enemy.     We continued our discussions and then a woman volunteered to be interviewed.   I wanted to demonstrate a narrative interview and the process by which we arrive at a shared story or metaphor for the illness. This woman whom we will call Ursula had migratory pain which rotated between her lower legs, elbows, neck, shoulders, back, and hands.   I asked for her explanatory story.    She said the doctors said that she had an autoimmune process had created her pain.   Her other story was that she was carrying the pain of her ancestors.   Medically she had been diagnosed with celiac disease, sarcoidosis, and Sjogren's syndrome.   She said her pain had been present for as long as she could remember.   As a small child she spent time in the hospital frequently for injuries.   She dislocated joints, cut herself, sprained herself, and on and on.   Between incidents she felt ok.   I inquired about her carrying the pain of her ancestors.   How did she arrive at that idea?   She said, from reading, feeling that it fit, and knowing what she knew.   "I carry their stuff.   Not with my permission except I must have agreed on some level."
"What is this stuff?" I asked.

"Negativity, dysfunction, emotional pain, physical pain."   She said that she was carrying something that" I can feel but cannot see.   It's a heaviness in body, a weight, a darkness, a blackness."   I remarked that this stuff was hard to see.   That you couldn't pet it, touch it, or see it.   It didn't walk across the lawn.   You couldn't eat it and it couldn't eat you.   (This was one elder's definition of "real" for me.)

Ursula went on to tell about her childhood physical abuse from her mother and sexual abuse from other family members.   Those experiences led her to feel unloved, disrespected, and not allowed to live a life free from danger.   At age 17, she left home.   From then on, she lived in a manner in which she felt loved, respected, and free from danger.   She said she was confused because she'd tried forgiveness and that hadn't worked.   She believed this was because she had more healing to do.   I asked her if she had talked to her pain or her joints.   She had, she said, but they were strangely silent.     I poked at her story in various ways, trying to understand her assumptions. I'd have to watch the video or read the transcript to understand how we got there, but we arrived at a shared metaphor of Ursula and this stuff as a painting with her standing in the middle of a dark and gloomy, bleak landscape without any color, and full of shame and pain.   The music playing was from Sibelius -- ponderous and solemn.   The painting was kept in a back room, away from the exhibition space of the museum.   Its only audience consisted of her husband and her two best women friends.   Nobody else was allowed to see it. "I have other paintings," she said.

"What are they?"

"I have a beautiful painting of me at the seashore in a tropical environment with deep blue water and light blue sky.   I have another painting of me in a forest surrounded by animals and my dogs.   These are my happy paintings.   We talked about the concept of the desirability of being pitiable, as in worthy of others' pity.   I told Ursula that back home on the Rez instead of hiding the gloomy painting out of side, a person might put it up on a billboard outside for everyone to see because of the desirability of being worthy of pity.   Aboriginal participants agreed that this fit Australian local culture, too.  

"You see," I said, "in dominant white culture you learn to hide your misery and shame and pain, but in other cultures, you bring it out for everyone to see as your legacy, your badges of courage, your medals of honor.   You can be proud of how you have suffered because on some level, you do it for the community.

Then we had our lunch break.

After lunch my task was to demonstrate to the participants how I would create a ceremony for Ursula in an office space in which I couldn't burn sage or tobacco or any of my other tricks.   All I could do was sing and talk.   Rocky assisted me.   Her ancestors (insert "My intuition if you don't believe in spirits) told me that they had a hard life and lived in great hardship.   Then we sang an invocation song, invited her ancestors to join us, sang an honoring song for them, and then invited Ursula to tell positive stories about them.   This proved to be very difficult.   "How do you expect them to come if you only tell negative stories?" I asked.   This was a new concept to Ursula.   She struggled and slowly found positive stories to tell about her mother, grandmother, grandfather, brother, uncle, and great-grandfather.   Once we had some positive stories, I could ask them to speak through anyone present in the room.

What emerged was a presentation by Ursula's grandfather that her grandmother and mother had done the best they could.   They had hard lives.   They were banana and dairy farmers and life was difficult.   We suggested that she needed to find more positive things to say about them.   Probably, now that they were dead, they had moved forward and perhaps they resented being presented so consistently so negatively.   Maybe she needed to tell positive stories about them.   I told her about being taught only to speak positively of the dead because they could get mad at negative comments.   We announced to her ancestors that the storage shed in which they were keeping their "stuff" was closing and they would have to come get it or it would be sold in auction.    I suggested more humor and more respect for her ancestors.   Ursula felt much better, lighter, and less dark.   What had happened is that we had moved her relationship in the past into a relationship with her ancestors in the present, which could be a very positive move toward health.

We closed with "doctoring", which is energy medicine North American aboriginal style.   Following was a discussion of the sweat lodge ceremony we would be doing the next day.   That brought us to the end of the day and we left for another marvelous dinner at Pauline's house.   Traffic was becoming intense because Sydney was having mardi gras.   We pointed out that it couldn't be mardi gras because it wasn't Tuesday.   It has to be samedi gras.  The Australians weren't amused.   This was the biggest gay parade of Sydney.   How different from what we knew from New Orleans!   Not very Catholic at all!   Traditions change across the ocean.   Who knew!   Tomorrow we will do a sweat lodge ceremony for those who want to come.