Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?



Monday, July 15, 2013

Poor Trayvon



Well, the George Zimmerman verdict is out, and I suppose every Blogger worth her salt will have to have something to say about it today.

I'm not a lawyer, so I don't have an opinion about the evidence or the jury, or the conduct of either the prosecution or the defense, or even about the Stand Your Ground law. Well, yeah, I do have something to say about that, but it's not a legal opinion, strictly speaking.

These kinds of laws spring from a state of mind peculiar to regions that historically were made up of scattered, rural, generally agricultural or herding societies who did have to protect their own land/livestock/homes/families because there was no law close enough around to do it. Pro-actively, the successful men in these societies projected an über-male, physically over-bearing persona in order to cause potential criminals to steer off for other parts where presumably they might find easier pickings. It was a matter of honor to be able to protect your boundaries, to be able to project that sort of image, and by extension if somebody messed with you or your stuff, well, then, your honor was at stake until you could even up the score. 

I can't say anything psychological specifically about George Zimmerman because I have not evaluated him, and I don't have access to anybody else's evaluation of him. Heck, I haven't even watched the non-stop coverage of the trial. But I can say, as a disinterested citizen observer, that George appears to the naked eye to be a bit like the fence-rider of old, ever on the lookout for rustlers who, if you will remember your US history, along with horse thieves back in the day could be hung on sight by whoever caught them in the act. This is, I suspect, partly why it looked so much like it was Trayvon rather than George who was on trial this past week. Indeed, I could not help but notice, some commentators persisted in referring to it as "the Trayvon Martin trial". The mentality is still that pervasive.

We don't need those kinds of laws any more, but they and the personalities they serve persevere. As does the gun violence that goes with them. 

If you see yourself as a victim, which, weirdly, an increasing number of white males in this country do, or if you merely fantasize yourself engaging in various make-my-day type heroics, you may find like-minded folk in the gun and prepper communities (there's a lot of overlap between the two). Stand-your-ground laws were written for you. And so you may end up going about your daily business locked and loaded, spoiling for a fight. You don't even have to be part of a neighborhood watch or other, similar, organization. You can self-appoint. Your real-world perceptions are filtered through the movies running through your head, which in turn are heavily influenced by the paranoid poppycock you read on prepper and gun websites and in their magazines and newsletters, to the detriment of your grip on reality. You would be what the American Rifle Association calls an Armed Citizen. They even have a monthly column called "The Armed Citizen" in which they congratulate each other for shooting alleged criminals. 

But I digress. 

Anyway, one day you find yourself in a situation which seems to you to call for a violent response. Instead of the dozen other things you could do, or not do, in this situation, you draw your weapon. You're not reluctant. You're not saddened by it. You are justified. This is, after all, the fulfillment of a long-cherished fantasy. You genuinely don't 'get' why anybody else would be horrified at what you've done.

This would happen even if there were no stand-your-ground laws, but at least then there might be some justice for your victim afterwards.

But I am not a lawyer, so no, my only real opinion is from my point of view as a mother, and that is that justice was not done here. It seems to me that part of the whole point of the USA is that a person -- most especially a child -- should be able to walk the streets of his or her community in peace and safety. And anyone who violates that is in violation of some law. Be it written or ethical or moral, he is in violation. He has violated the peace of the community, and the safety of all of its citizens. He has violated the faith and trust that we have in our neighbors.  

I don't see how Trayvon's parents can have any peace at all until we as a nation stand up and say this. 

Monday, June 17, 2013

From the In Box

The most recent edition of Professional Psychology: Research and Practice landed in my In Box this week, and in it was an interesting study on a multifamily group program for vets with PTSD at the Oklahoma City Veterans Affairs Medical Center (VAMC). 

It has long been known that while good family support helps people recover from PTSD, the PTSD itself can alienate the sufferer from family members, depriving them of support. Bad family relationships actually interfere with treatment. With this in mind, the Oklahoma City VAMC set out to adapt a multi-family group approach to the specific needs of veterans. They call it REACH, for Reaching out to Educate and Assist Caring, Healthy families. 

They've collected data from about 95% of their participants, over a period of a little over four years, and they believe that it works. But it's the first such study specifically with veterans diagnosed with PTSD, and it's a small study so these results are very preliminary.

This was a longitudinal study with no control group, meaning there were no vets wait-listed for it or in some other form of treatment (comparison groups of both types would have been ideal). And the data on improvement was reported by the study participants themselves, to the therapists who both provided the treatment and conducted the research. As with any study of this nature, it may appear to work better than it apparently does, for a couple of reasons:
  1. People can get better over time, either because 'time heals all wounds,' or due to other things occurring in their lives during the course of the study. The authors performed a statistical test for this, but still, a control group would have helped to tease out how much improvement is due to the program itself, and how much due just to life going on. And since some study participants were receiving other treatments at the same time, there's no telling exactly what improvements are due exclusively to REACH.
  2. It is well known that when people invest a lot of time and energy in something, there's a psychological bias towards finding it worthwhile. This is true for researchers and participants, and is bound, in this kind of study, to influence the reporting and interpreting of results.
One thing that makes the results stronger in this case than in some studies to come out of the VA system in recent years is that the researchers didn't "cherry-pick" their participants, which is to say that nearly everybody who wanted in, got in. Cherry-picking is frequently a problem with treatment efficacy studies, as anyone with co-existing conditions, or who is taking medications, is ruled out, and definitions of the diagnoses that get you into the study are very narrowly defined. This results in the study population not looking much like a typical clinical population. For the purposes of this study, persons with active addictions or who were suicidal or homicidal were screened out, but these are criteria that are almost universally applied in clinical practice as well, so does not much affect the applicability of the results. 

Even better, their definition of "family" was open and welcoming: A veteran could bring her or his adult significant other of nearly any description -- a lover, a spouse, a parent, a sibling, an adult child, or even a friend. 

Veterans ranged in age from 22 to 85, which would include the Korean War if not World War II, and that both adds to and detracts from the strength of the study. Different "cohorts" (age groups) serving in different wars could have widely varying backgrounds and combat experiences and therefore respond very differently to a treatment. Also, older vets, by definition, have a more chronic form of PTSD. An average age, as in this study, of 55.8 years means that this is something that may not work as well for very young folk just back from Afghanistan or Iraq with their differing upbringings, combat experiences, and acute onset of PTSD as it does for VietNam-era or Persian Gulf veterans.

Unfortunately, the study population wound up being almost all white (non-Hispanic) straight males, so we don't know, pending further study, whether this program would be equally helpful to people of color, women, LGBTQQI folk -- never mind veterans or family members who fall into all three categories at once! 

Of course, there's no reason to believe that it wouldn't work for a wider range of folk, since groups in general have been studied for over half a century now and the results are consistent. It works for nearly everybody, for nearly every problem. It's just that with this study, the authors could not claim with any certainty that this particular protocol would work for other than adult, straight, white males of a certain age.

From the description, REACH appears to be a nicely-structured program, with a generous time allowance for assessment and engagement with the program, and a nice consolidation/follow-up phase to help families maintain and elaborate on their gains. At the same time, it does not appear to be so structured as to be a cook-book-y, overly technical approach. And folks liked it! Some of them reported that the meetings were the high point of their weeks. Participants knew more about PTSD when it ended than they had when it began, and some of their symptoms improved. They learned coping skills, and their relationships improved. 

The authors note that in a study of this sort, while you can say you're pretty sure the program helps, it's hard to say exactly what components of the program are most -- or least -- effective. That makes it a bit of a crapshoot whether you can replicate the results elsewhere. What if, for example, one of the only four psychologists running the study is just especially talented, and no matter what she did, her people would get better? On the other hand, if the standard curative factors of all effective groups were in operation here, you could do REACH or any other variation of multifamily group and get the same results anywhere. This is why we like to see multi-center studies, or studies replicated elsewhere producing similar results. However, when you are running only 4-6 vets and their families through at a time, and the whole process takes nine months, as this one does, we'd be waiting a minimum of four more years for the next study -- and that's not counting the time to organize and fund a study, write it up, and get it into print! So I think you will see a lot of psychologists running with this one, and soon. 

Although VA is mandated to provide some form of family education, the REACH program specifically does not appear to be available at our local (Atlanta) VAMC yet. However, the study's authors will make the materials needed to conduct the group available to any psychologist who wishes to lead one. If a half-a-dozen or so of you are interested, I think we could have one up and running by the end of summer. Just let me know!
Fischer, E. P., Sherman, M. D., Han, X., & Owen, R. R. (2013). Outcomes of
    participation in the REACH multifamily group program for veterans with PTSD and
    their families. Professional Psychology: Research and Practice (44), 127-134.
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Monday, June 10, 2013

Think With Your Whole Body

We like, in Western society at least, to think of our mental or spiritual selves as "me" and our embodied selves as separate, an "it". One effect of that is that we get out of touch with what's going on with and in our bodies, and wander off in our minds--into the future, the past, or some parallel universe that is neither past nor future, but which is certainly not here or now either. And the primary effect of that, I have found, is bodily neglect and abuse along with a good deal of unnecessary tension and stress. 

But what if we treated our minds and bodies as the unified experience that they are? What if we thought of our minds as one with our bodies, and rested and fed it like the organism it is? What if we treated our bodies like part of our minds and attended to what it was telling us about our selves and the world all of the time? Our bodies are powerful sources of constant streams of information and wisdom, and when we only think with the frontal lobes, we're only using a fraction of the potential available to us. 

Next time you are, say, eating breakfast, and notice that your mind is wandering, try bringing it back. Take a nice, normal breath in and attend to it -- really attend to it. Notice what it feels like coming in -- how the air feels passing over your upper lip, into your nostrils, down your throat. Notice the rise of your chest. Can you scent your breakfast? Taste it? Bet you hadn't even noticed your breakfast while you were doing all that wool-gathering!

When you breathe out gently, slowly, naturally, also notice what that's like. Then, what do you see? If you are like me, you might have been completely blind for some time to the look of the morning sun slanting through the trees in your yard, or to activity of animals or people around you. What have you not been hearing that you can become aware of now?  The refrigerator humming? The dog's toenails on the kitchen linoleum? Or perhaps you were numb to the warmth of the mug in your hands, the feel of the chair under your butt or your elbows on the table.

And as you do all this, notice how your body relaxes. I'll bet where your mind was before wasn't fun. You were missing someone or something from the past, regretting something you had done or failed to do, planning your workday, or worrying about something in the future that might not even come to pass. And your body was responding by becoming tense. (All that tension, over time, besides not being much fun is rough on your health.) You may find that 99 times out of 100 when you check in using this technique, your mind was yelling that the sky is falling but when you listen to your body it will tell you that right this two seconds it's actually all quite good. 

And while you were in that place that is neither here nor now, you may have neglected to notice that your body was stiffening in its current position and needed to adjust, or that you were tired, or cold, or needed to pee. That kind of neglect leads to abuse. We don't rest our bodies, or feed us, or clothe us warmly enough, or move ourselves around to keep limber and strong. Or if we do feed ourselves, we eat stuff we don't even enjoy because we're not paying attention to what we have a taste for or when we're full. We put ourselves and leave ourselves in situations we don't like, with people who are not good for us, in the meantime bypassing or at least not fully attending to good relationships and pleasurable activities because we are trying to think our way through life with our frontal lobes and ignoring what our bodies are telling us. We're where we think we should be, doing what we think we should, and we've doped that out with a fraction of the data we need to make genuinely good decisions.

It's a really powerful skill, thinking with your whole body. And although the daily practice of sitting meditation or yoga helps you get better at it, neither is absolutely necessary. You can do it any time you notice that you are all in your head and someplace else: Just take a nice, normal, gentle breath in, following it, and then let it out, again simply being aware of it. And then become mindful of the rest of your body as well. Mindful -- as in, fill your mind with this and kind of let all the thinking activity go for a minute. What's your belly doing, saying? Your feet? Your hands? Your skin? and so forth until you have developed an awareness of all of your senses and parts and systems. Hold all of that in your mind at the same time for a bit. If you do it often during the day, you'll find it becoming more natural to do more of the time. 

Try it. You'll like it.
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Monday, May 6, 2013

International No Diet Day

In honor of International No Diet Day, I thought I'd share my own diet history. 

My mother was a dieter, which is kind of ironic considering that she was so skinny when she was little (the story was, she'd been sick with something) that the family doctor told my grandmother to give her a beer every day to plump her up a little. Even in her teens and early adulthood, the photographs show a slender, athletic build. But that's how the diet industry works -- according to that old sales adage, create a need then fill it. By the 1960s, she was convinced she was fat, and for decades went on every crazy diet that came out, including, once, The Drinking Man's Diet. So dieting, self-hate, and alienation from my own internal signals of hunger and satiety were modeled for me from an early age.

The sixties also, not coincidentally, was the decade in which I hit puberty and Twiggy became an international sensation. I turned 15 the year she began her career. My friends and I were all soon on diets, as our bodies began to fill out in the way nature intended and we wanted them to look like Twiggy's. I remember at 13 skipping lunch to lose weight, when I had very little to lose (I think back then I hovered around 105 lbs) and at some point in there learning to count calories: I had my intake down to 800 calories a day some days. God only knows what kind of damage I did to my growing body during those years, all supported by the messages we were all getting from Seventeen Magazine, television ads, and just about everywhere else in the media, and my own mother. 

That began the weight cycling. I was never fat, hovering around 125 pounds by the time I got out of college, but I was convinced I was. 

By the time I'd got married and started into my first round of graduate school, I'd discovered feminism, along with their take on the objectification of women and diets. For a time, I was free of dieting, learning to eat intuitively, and loving it. But the diet industry is seductive, and by the eighties they'd learned to associate health with weight loss to not only scare us into dieting but convince us that we were actually doing something good for ourselves.

It was in the eighties that I quit drinking. Of course, I lost a little weight right off, and somehow that triggered another round of dieting. I became a little (okay, maybe more than a little) obsessive about it -- there's page after page after page of wasted journal space taken up with little more than calorie counts and daily records of my weight. I lost 30 pounds, which was probably 25 pounds more than I "needed" to. I started passing out and falling, and my friends began to express concern. I was a size 10, struggling to get into an 8, because I had some vague memory of wearing an 8 in middle school and thought that was where I "should" be.

I started graduate school again, and my weight began to creep up as I didn't lift anything heavier than a textbook, I wasn't in charge of the cooking at home any more, and I was under massive stress. By the time I graduated I was, for me, positively huge, weighing in at nearly 185 pounds. And somewhere in there, I got, for the second time, the message that dieting was not the solution, but the problem. When it was relevant to the topic in my psychology classes, I would spin around in front of the class and tell my students, "This is the body you get with dieting." 

But the diet industry is seductive. Somehow, between the fifties and the year 2000, when I was diagnosed "pre-diabetic" ("pre" anything is a whole 'nother problem, more to do with the pharmaceutical industry, and we'll save that rant for another day), the diet mentality had thoroughly infiltrated the medical profession. Doctors were convinced that it was weight gain that led to diabetes, for example, and not the other way 'round, as recent research suggests, and I was placed on a medical diet. Off came the pounds. Back came the obsessive behavior. Until Mr. Wood got sick and had to go out of state for treatment. 

Because here's one of the things about diets. They can call them 'lifestyle changes' all they want, but they're not. Because if they were, they'd be pleasurable and sustainable. But they're not. Instead, they're onerous and unnatural, and when you get busy having a life, there's not time for all that obsessive behavior, and the diet -- because that is what it is -- goes by the wayside. 

Feminists, by the way, would say that is part of the point. The Incredible Shrinking Woman has been used as a metaphor (I wish I could remember by whom, so I could cite her appropriately, but unfortunately I cannot) for what all patriarchal societies, ours not excepted, would like to do to all women -- make us smaller, and smaller, and smaller, and less visible, less powerful, until we disappear entirely. And occupy us with silly things like our hair and our makeup and our pants size so that we don't have time or energy (or money) left over to be intentional actors in the world outside our own skins. 

Anyway, back came some of the weight. Interestingly, however, the diabetes did not come back. Why? Because I actually had, in and around the diet crap, made some actual lifestyle changes. More complex carbs, more fiber, for example. Less stress. Which is what research over the last decade has been showing more and more -- that if you make a lifestyle change having nothing to do with cutting calories or losing weight, a real lifestyle change like more exercise, or more fiber, or less salt, well then. Your health improves. Imagine that! And those are achievable goals, whereas anything more than temporary weight loss is a chimera.

Fortunately, before I could go on my next diet, I discovered Health At Every Size (HAES) and re-discovered intuitive eating. I have not dieted a day in my life for the past two years, and -- surprise! -- my weight is absolutely stable. My labs are fine, too. My blood pressure is fine. My total cholesterol ain't so hot, but that's mainly because my good cholesterol is too low (and my heart attack risk remains rock-bottom for a woman my age, according to the Framingham tables).  My blood glucose is fine. As for my mental health, I have finally divorced food choices from morality, from character. I have no guilt about my eating any more. I don't criticize or dislike my own body but am coming to appreciate what an intricate marvel it is, and to appreciate it for what it can do. No obsessive-compulsive behavior: What I eat or don't eat doesn't rent the best spaces in my head any more. 

The third time, as they say, is the charm. I am experimenting with new foods, eating intuitively and meditatively and enjoying my meals as the sensual experience they are intended to be. And the funny thing is, this business of learning to think with my whole body instead of just my head is expanding into other areas of my life and I'm learning to take care of myself in other ways as well as feeding myself better, learning to enjoy other experiences more. 

This is International No Diet Day. Try it. Just say "no" to food rules today. Say "no" to moral judgments on your eating. Say "no" to character assassination based on your appearance. Just for one day, don't police other women's bodies, either, or tell them what to eat or not eat. Just for today, listen to your body. Eat what you are hungry for. Stop when you're not. 

Try it. You'll like it.
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Monday, April 1, 2013

Fat and your health

This is an odd little piece that doesn't have anything to do with anything other than that these two stories have been on my mind a lot lately.

Some time ago I read an article on ethics that took a dying man to task for not making arrangements for his practice, not telling his colleagues and clients he was sick, continuing to work after he was probably no longer competent to, etc. The writer never addressed what to me was the most poignant part of the whole story, that as he lost more and more weight, becoming thinner and thinner as he dwindled away to nothing, his colleagues congratulated him and told him how wonderful he looked. Only in our culture would drastic weight loss not be an alarm signal that something was drastically wrong. But nobody in his practice, apparently, ever thought to ask him if he were ill. My heart aches when I imagine how each of those well-meaning compliments must have only increased his isolation, and what a lonely death his must have been in the end.

The other story I have for you today is of a woman who had a tumor growing in her belly. It went undiagnosed for a long time because everybody--including her weight loss doctor--assumed it was because she was fat. She'd even complained at the weight loss clinic that no matter how much she dieted, no matter how much weight she lost, her belly wasn't shrinking. It was uncomfortable. It finally got so big that it was about to burst, as I understand it, but it wasn't until she started throwing up green bile that she went to the local Emergency Department. Surgery to remove it nearly cost her her colon, and complications from surgery to repair that almost cost her her life. It did all together cost her 15 months off work, so sick she was unable to walk around her own house. 

Only in our culture could we be so out of touch with our own bodies. 

As I wrote this, Zemanta threw up article after article, photo after photo for me to select from to illustrate my stories or to link to. Every one of them was about diets--most for useless junk like green coffee. Not one article, not one graphic raised concerns about weight loss being a sign of illness. Not one. And yet among wild animals and human cultures of the past, that's universally what it was. A nice, healthy layer of fat has always been a sign of plenty, and of well-being. Bears put on fat before they hibernate. Hummingbirds put on weight before they migrate. Old horsemen used to talk about 'good keepers', that is, horses that could maintain their weight.

But beyond that, I suspect that prior to the last 50 years or so, we've been in better touch with our own bodies. Surely people are born knowing how to eat--half a million years of evolution would have seen to that--but over the last half-century we've let the "experts" and the diet industry tell us what, how, and when we should eat. Signals that should come from within now get ignored in favor of arbitrary directions from without. It's no surprise that few of us know when we're hungry any more, never mind what for, or when we're satisfied. And it would not surprise me if that, in turn, led us to be out of touch with other internal signals, from signals that we are getting tired and need to rest to signals that we might be getting sick. 

If that is so, then might not mindful eating be the start of a path back to a lot more mindfulness, toward getting to know many aspects of our internal experience, and perhaps even a step toward approaching others' experiences free of erroneous assumptions about weight and diet?
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Monday, March 25, 2013

On Best-Laid Plans

English: Wood mouse (Apodemus sylvaticus) – wr...
English: Wood mouse (Apodemus sylvaticus) –  (Photo credit: Wikipedia)
And how they really do "gang aft agley". 

I had planned to post to the blog today. And before that, I'd planned to do my taxes this weekend. And before that, I'd simply planned to go to work on Friday, like millions of other ordinary working folk around the country. 

But events conspired to disrupt all that. One thing led to another and more piled on top of that until by Friday I was going to have to be the one to deal with a household crisis. It couldn't be delegated, and it couldn't be put off. More dealing ensued, and continued throughout the weekend, so that here we are, on Monday morning, without a post. 

 When we are used to making and executing plans with ease and regularity, it can be astonishing to learn how little our intentions matter to an indifferent universe. Still, I consider myself blessed that my particular circumstances could be resolved with the application of a little cash and elbow grease, and that we were able to just roll with it. Others, like Mr. Burns's little mousie, are not always so lucky.

Clients and friends had their plans disrupted, too, with family members going into hospitals around the country with problems of varying seriousness. And every day we turn on the news or pick up the paper and see how sadly things have gone south on others, promised joy turning to ashes in their mouths. My thoughts are with all of those people this week, as I pick up my plans where I left off, and resume my normal routines--which should include a real post next Monday.
The best laid schemes o' Mice an' Men,
Gang aft agley,
An' lea'e us nought but grief an' pain,
For promis'd joy! 
Robert Burns, To a Mouse (Poem, November, 1785)
Scottish national poet (1759 - 1796) 
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Monday, March 18, 2013

Jimmy was right

Jimmy Carter, former President of the United S...
Jimmy Carter, former President of the United States. (Photo credit: Wikipedia)
"There are many things in life that are not fair." 
-Jimmy Carter
When he said that, I was young enough and naïve enough to expect that life should be fair, and so to be appalled at his comment. I loved Mr. Jimmy, but he broke my heart with that line.

In the intervening years, though, I have learned that life is, indeed, manifestly not fair and that when we persist in demanding that it should be (there's that word again), we set ourselves up for all sorts of misery.

I am not saying that we should not be willing to step up to address inequities when it is in our power to do so, only that in expecting the universe to operate along some sort of moral lines we add to the unhappiness that is already there. And sometimes we create the unhappiness.

I have come to believe that the sooner and more fully we can embrace the notion that we need to be able to accept life on life's terms in order to live happily, the better off we'll be. Harsh as it may sound, then, the real question becomes not "Why is this happening?" but "What do I intend to do about it?"

I suspect that when bad things happen, this is nobody's instant response. We all need a little time to wrap our heads around the new state of affairs, to take stock of things and begin to see where we stand now. But then we need to dust our butts off and get back up on that horse and ride it. Wise old horsemen would tell you that if you don't, the horse understands that he just got the better of you, and he'll remember that next time. In life, the message is the same except that you're the one getting it. Be sure the message you send your self is that you can cope, you can deal. 
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