Northwest Narrative Medicine

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Narrative medicine, Pacific Northwest style, strikes me as something worthwhile. Frontier, boundary pushing narrative medicine. Pencils (and pens, and laptops) with golden wings! We now have (thanks to the folks in Portland, Oregon) a Northwest Narrative Medicine Collaborative.  Next month (October 20-22nd) they will hold their second annual Narrative Medicine Conference in Portland, Oregon. I am honored to be a part of it and will be giving a keynote address titled “Endurance Test: The Limits of Resilience” in which I’ll examine the unintended consequences of the often saccharine sweet resilience research and will, instead, propose the concept of endurance in our work and lives. Endurance, as described by psychiatrist and anthropologist Arthur Kleinman, makes so much more sense to me than does resilience—especially in the times we are living through. Kleinman writes:

“What helps us endure? And I mean by endure withstand, live through, put up with, and suffer. I do not mean the currently fashionable and superficially optimistic idea of ‘resilience’ as denoting a return to robust health and happiness. Those who have struggled in the darkness of their own pain or loss, or that of patients or loved ones, know that these experiences, even when left behind, leave traces that may only be remembered viscerally but shape their lives beyond.”  (Arthur Kleinman, “The art of medicine: how we endure.The Lancet. January 11, 2014. 383: 119-120.)

On (Homeless) Self Promotion

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Happy 1st birthday to my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net. There is this upcoming sale of the e-book for all you e-bookish fans.  It has been a fascinating and fun year and it has taken me places I never expected to go.

Fight Hate

img_1244I grew up in rural Virginia surrounded by White supremacists and the KKK. I went to school with—and received direct threats from—the son of the Grand Dragon of the KKK. Hate groups are, unfortunately, alive and all too ‘well’ today as they were then, and according to the wise folks at the Southern Poverty Law Center, they are proliferating in number. Hate groups are not confined to the South but they do seem particularly prevalent there, especially White supremacist hate groups, for obvious historical reasons. It is both disingenuous and dangerous for Virginia politicians, including Governor Terry McAuliffe and Mayor of Charlottesville Michael Signer to claim that the White supremacists at this past weekend’s hate rally were “not from here.” Of course, they likely represented almost every state and dark, dismal corner of our country. But of course, they were born and bred Virginians as well. It is dangerous for us to deny that hate starts at home, that hate is present where we all live, in each and every community. Fight hate. Here are ten ways to fight hate in your community, brought to you by the Southern Poverty Law Center.

Hate crimes are a public health issue, recognized as such by the American College of Physicians in a recent statement, by the American Public Health Association, the American Psychological Association, the American Nurses Association, and by a growing number of other professional associations.

And, because the memory of the following experience was brought back for me over the past few days, here is my story of my first run-in with the KKK. I was ten years old. Oh yes, and when I was back in Virginia this past fall right before the November election, on the exact farm where this KKK rally occurred, there were huge signs for both Trump and a White supremacist/nationalist group.

One late summer day I was riding in our VW bug, my mother driving on back roads from the airport, within view of downtown Richmond, not far from Oakwood Cemetery. We had just dropped off a camp counselor who was flying back to college. I was ten, sitting in the backseat, slumped against the right side window, reading a book, vaguely registering the countryside and farms we were passing, when my mother slammed on the brakes.

“Damn!” I never heard my mother curse, so I looked up quickly.

“What?” I asked.

“Keep your head down and stay quiet,” she said, adding more softly as she turned off the engine, “It’ll be OK.”  I could see her leaning forwards, both hands tightly clutching the top of the steering wheel. I slumped down in the seat while quickly peering out the side window to see what had stopped us, to see what would be OK, to see what she didn’t want me to see. I figured it was a bad car accident and she didn’t want me to see the dead or injured people.

It was approaching dusk, the witching magic hour for the waning sun. The field next to us glowed golden, with large rectangular hay bales strewn about the field of wheat stalk stubble. Hovering over the field, suspended in the thick damp evening air were shining motes of hay bits, effervescent like Fourth-of-July sparklers. With our car engine turned off, the sound of cicadas and crickets created a curtain of white noise, as mesmerizing as the floating hay.

“ Evening, ma’am. Don’t mean no trouble. I gotta’ stop you here awhile. There’s a meeting that’s passing through, that’s all. You can get going in a minute or so,” a man’s voice, polite, official-sounding, with crisp words stuck in a slow Southern drawl, came in my mother’s open window. I looked between the seats and saw a spotless white-gloved hand cupped over the doorsill. Behind that was blazing white with a thin, trickling, blood-red cross, above the cross was no face within a white mask, pale thin lips moving within an elliptical cutout area. From the words spoken and the weight of the voice, I expected to see the uniform of a policeman. When I first saw the white mask, I felt disoriented and had to remind myself it wasn’t Halloween. I stayed quiet, huddled down behind the seats. As the man walked away, I looked out the front windshield to see where he was going. Up ahead, perhaps fifty feet away, was a swarm of ghostly pointed-hat masked figures swirling around a huge bonfire. It took a moment for me to see that inside the bonfire was a ten-foot dark wooden cross.

“What’s that and why are they wearing those weird costumes?” I asked.

“Shhhhh—I’ll tell you later. Stay down and stay quiet,” my mother said.

Absorbing the fear in my mother’s voice, I sank deeper in the seat, but moved over in the middle so I could see out the front windshield at the fire and the figures. Several of the white-clad men reached into the fire with long wooden sticks and withdrew flaming torches. Then en masse, with fluid amoeboid movement, the group came toward us, sucking in lone figures as it streamed forward. I heard deep-voiced chanting, words indecipherable as a foreign language. They grew louder, surrounding our car, lighting the inside with their glowing whiteness and lit torches, gently rocking the car as they brushed past it, moving across the road, then thinning to double file down a dirt path that cut through the next field. The comforting, familiar smell of wood smoke followed them.

I didn’t hear my mother start the car. We were speeding away, screeching around bends in the road. Reflected in the rearview mirror, I saw my mother’s face set hard as stone, etched with the fierce anger I seldom saw. I was more afraid of her anger than I had been of the men we had seen. I stayed quiet, huddled down in the back seat, bracing myself for the rough ride. When we got home she disappeared into her bedroom, talking quietly with my father—so quietly that I couldn’t make out what they were saying, even with my ear pressed against the rough stucco wall between our bedrooms.

At the dinner table that night, my father told me we had been in the middle of a Klu Klux Klan meeting. “They’re racist white men who wear those costumes to look like ghosts of Confederate soldiers to scare black people, and to scare white people who don’t agree with them, like it scared your mother.” As I slowly chewed a mouthful of food, I considered this information. The ghostly man who had stopped us seemed polite, a Southern gentleman. Being in the midst of the KKK meeting had been exotic, dreamlike, seductive—almost beautiful. I knew that what I had seen, the way I had seen it, was not something to discuss. I swallowed the dissonance between my mother’s reaction and my own experience of the encounter.

The dissonance remains. It took living out of and looking back at the South to understand that ghosts becoming part of the landscape are something not to relax into. The landscape of my childhood is a landscape of half-buried violence, covered with violets, punctuated by deep, abandoned wells. The roads leading back to it are as twisted as the country roads I grew up on. Within the accretive layers of nostalgia lies the sludge of orange dust tasting of blood. I both fear and yearn for the complexity, the offbeat rhythm of the South that has formed me.

From the chapter “First Families” included in my medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net.

It’s Time to Read (and Write) Like You Give a Damn!

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Authors at the University of Washington Libraries’ 12th Annual Literary Voices event, May 2017.

“It’s time to read like you give a damn!” is the tagline admonishment to the University of Washington Health Sciences Common Book series, of which my book, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, was this last academic year’s Common Book. I have added “write like you give a damn!” to remind me of why I write, why I read, and why I do the work that I do. It is the moral imperative of working towards a socially just world. As George Orwell stated so eloquently in his essay “Why I Write,” there are four great reasons to write:

  1. Sheer egoism
  2. Aesthetic enthusiasm
  3. Historical impulse
  4. Political purpose—”and political purpose in the widest possible sense. Desire to push the world in a certain direction, to alter other people’s idea of the kind of society that they should strive for.”

Catching Homelessness was published a year ago today. I am grateful for what the years of researching, writing—and living—the book have taught and continue to teach me. I think about the wise words of Sherman Alexie (as quoted by the wise woman author and teacher Pam Houston—whose 1992 book Cowboys Are My Weakness is partially responsible for my cross-county move to Seattle in 1994). This is from a reading Alexie gave in July at the Institute of American Indian Arts Low Rez program:

“How are you going to tell your story, so that people who don’t know anything about your story get something from it. And you are not in charge of what they get. Sure, you are vulnerable, but you are still a storyteller.”

Sherman Alexie was speaking about his new memoir You Don’t Have to Say You Love Me (New York: Little, Brown and Company, 2017), which is mainly the story of his complicated grief for his mother, Lillian Alexie, who died several years ago. And about the health effects of intergenerational trauma that he has experienced. In his memoir, Alexie writes about his childhood growing up in poverty on the Spokane Indian Reservation in Washington State—about his serious health issues and childhood sexual abuse—about his mother’s rape and discovering that she is the product of a rape. I am dismayed at the insensitive (and as I read it, racist and misogynistic—questioning, for instance, the veracity of his mother’s rape) June 13, 2017 NYT review by Dwight Garner “Sherman Alexie’s Complicated Grief for his Mother.

Alexie, in a recently published open letter, writes eloquently about the re-traumatizing and triggering effects on him that having his memoir out in the world has had. He states that he needs to “take a big step back and do most of my grieving in private.” While his memoir remains in the public domain, he has canceled the rest of his promotional tour events for the rest of the year in order to take care of his mental health—to tend to the ghosts of his mother and ancestors.

I applaud his letter and his honesty. I also understand what he means when he writes of ghosts and hauntings. Part of my motivation for writing Catching Homelessness was to deal with the presence of ghosts in my childhood and my life, which were and are marked by intergenerational trauma. One of the most frequent questions I have been asked by readers of my book is something along the lines of, “But tell me, did you really see the ghosts you write about?” As if a memoir, a book of non-fiction, cannot include something as unverifiable—as poetic— as a ghost? As if an educated, scientifically-grounded person cannot believe in, much less write about believing in, ghosts?  I imagine that the person asking me this question has had a fairly easy life. I’d like to think that they realize—at least at some level—their privilege in that regard and are genuinely attempting to reach for some level of empathy and understanding for what it is like to be haunted.  That is what “reading like you give a damn!” is all about: at the very least it is stepping outside your own comfort zone, finding the capacity for empathy leading to action.

And here I share the thought-provoking outreach packet for Catching Homelessness, put together by my social-justice-in-action colleagues at the University of Washington. 2016-2017 Outreach Packet copy

Catching Homelessness book launch and benefit for Mary's Place. Elliott Bay Book Company. August 2016. Photo credit: Karen Allman

Leave Things Better Than You Found Them

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Concrete jungle courtyard (when first built in 1947 and now) of the University of Washington Health Sciences.

Leave things better than you found them was a lesson I was taught as a nineteen-year old college student during my study-abroad experience. That, along with celestial and non-celestial navigation, how to sail a 125′ Topsail Schooner, how to survive a Force 9 gale off the coasts of Labrador and Newfoundland, how to identify a multitude of sea creatures—including a 70′ Balaenoptera musculus (blue whale), how to take depth soundings of a Newfoundland fjord while perched in the bow of a tiny dinghy, and how to write and type a scientific report while rolling around on the high seas. Oh yes, and the poetics of sea shanties. All skills and knowledge and experiences that have served me well in life, reinforcing for me that value of experiential, immersion study-abroad programs.

But it is the seemingly trivial lesson of leaving things better than you found them that comes back to me most often, including this past week during the vicissitudes of the latest round of “let’s mess up our U.S. healthcare system even more.”

During my S.E.A Semester study-abroad program, Captain Carl Chase, our taciturn and highly capable and salty leader, sat us all down the first day of our voyage and explained that, in addition to our academic and sailing and galley work for the next six weeks, we were expected to find one thing we could do to do leave the ship in better shape than we had found it. He left it up to us to figure out what to do and then he would provide the materials and guidance necessary to complete our project. My project became the carving of a wooden knob for the battered galley teapot which had lost its knob. I liked to complain about the difficulty prying the top off the teapot and then realized I could—and should—stop complaining and do something to fix the problem.

Whenever I find myself complaining about things, like the ugly weed-filled concrete planters in the main courtyard at work, or the direction our country is going, or the direction the profession of nursing is going, or any of the myriad of issues I care about, I remember Captain Chase and the teapot knob and try to find some achievable improvement I can make.

And I know I am not alone in this effort. For instance, the Canadian nurse writer Tilda Shalof was recently highlighted in the Toronto Star article and accompanying video interview, “Medical Waste Becomes Massive Medical Art Mural.”  As she prepares to retire from her decades working as an ICU nurse, Shalof turned the acres of brightly-colored plastic covers to various medical supplies into a beautiful art mural to adorn the hospital’s walls.

Skeletons in the Closet

IMG_2792.jpgOne evening this past weekend I watched the indie movie “To the Bone” (2017) which deals with the topic of eating disorders, particularly anorexia nervosa—with the highest mortality rate of any mental illness. People waste away, become skeletal like concentration camp victims, and literally starve themselves to death. Unless, that is, they are fortunate enough to be able to access effective and compassionate health care and recover from this devastating illness. As does the 20-year old lead character in “To the Bon,” Ellen, as well as the actress, Lily Collins, who plays her in the movie—and as does the writer/producer of the movie, Marti Noxon. Both Collins and Noxon have struggled with anorexia and Noxon based the screenplay on her own experience.

I had read about some of the controversy surrounding this film, including critique that it glorifies thinness and eating disorders in general, as well as that it can tigger viewers into a recurrence or worsening of their own anorexia. Although I am not in favor of the over-use of trigger warnings, I did feel that the brief written warning at the beginning of the movie was tasteful and appropriate. As I remember, it stated something like “The following movie includes content that some viewers may find difficult to watch.”

Having lived through anorexia as a teenager, and having provided primary health care to many young people struggling with eating disorders (and across the socio-economic spectrum), I can say that “To the Bone” is an honest, nuanced, and not overly-sensationalized depiction of the lived experience of eating disorders. The movie does not glamorize thinness or eating disorders. It appropriately alludes to the linkage between eating disorders and childhood trauma, including sexual abuse. The supposedly unconventional heroic physician in the film, Dr. William Beckham, played by Keanu Reeves, is borderline obnoxious in that Robin Williams ah-shucks smiley face sort of way. And the group home eating disorder treatment center where the main character Ellen goes in a last-ditch effort to find a cure, is a gorgeous and expensive-looking setting. It helps that Ellen’s elusive father (he never appears in the movie even for a family therapy session) is portrayed as having a well-paying job in order to pay for that group home inpatient therapy. Even patients with relatively comprehensive health insurance often have difficulty accessing such treatment for eating disorders.

My assessment is that “To the Bone” is a good and honest film about an important mental health issue, and it is written/produced by a woman and features mostly women in the leading roles (luckily, Reeves has relatively little screen time). I can see this film being used effectively in nursing and other health professions educational programs for many years to come.

  • A good resource for more information on eating disorders (including a toll-free, confidential help-line) is the National Eating Disorders Association.
  • And about that actual skeleton in the closet included in this post… It is a human (not plastic) skeleton enclosed in its own wooden closet on wheels and is located in the University of Washington School of Nursing’s new simulation/learning lab. I took her photograph last week and am currently trying to discover anything more about who she was.

U.S. Healthcare (Politics) is Bad for Your Health

FullSizeRenderThat U.S. healthcare is bad for your health is something that is well-documented yet not widely known. Last year, researchers from Johns Hopkins University published the British Medical Journal article “Medical error—the third leading cause of death in the US.” Yes, that is correct. The top three leading causes of death in the U.S. are (in order): 1) heart disease, 2) cancer, and 3) medical error—death resulting from medical/health care itself.

But lately it occurs to me that U.S. healthcare politics is bad for our collective health as well. Especially the current state of healthcare politics being bashed around by the U.S. Senate Republicans with their widely unpopular American Heath Care Act—now called the Better Care Reconciliation Act, but also referred to as Trumpcare. The latest estimates are that 22 million Americans would lose health insurance under the Republican Senate health bill.

Last night I attended the town hall meeting on health care by U.S. Senator from Washington State Maria Cantwell, held at the University of Washington. It was her first town hall meeting in many years and was well-attended with a packed lecture hall of 600 or so people. The vast majority of audience members were older (than I am) white people, and from the questions they asked (and the occasional heckling), most were way left of center and perhaps even left of left. There were several social workers and mental health therapists who spoke about the increase in anxiety and depression among their clients/patients over the Republican move to repeal and replace the Affordable Care Act. Talbots-wearing middle-aged white women spoke of their sons being affected by the current opioid epidemic (and at least one of which was introduced to opioids by a hospital stay), and about their young adult daughters getting IUDs placed by Planned Parenthood—not because they currently needed them, but because of their fears of losing access to birth control.

The questions and comments from participants of the town hall health care meeting were tightly controlled by a lottery system, with Dr. Paul Ramsey, CEO of UW Medicine and Dean of the UW School of Medicine serving as moderator. Senator Cantwell’s responses were, well, predictable and politically-calculated, but then that is to be expected.

The most powerful part of the evening came from an African-American older man standing in the balcony area, holding a hand-made small sign, who spoke out passionately about how no one was talking about the Black Lives Matter issues, and said he was currently homeless, living on the streets near the University of Washington, and had a hard time getting access to mental health treatment. He spoke ‘out of turn,’ not having a lottery ticket number called. He was flanked by two police officers who, thankfully, allowed him to speak. Some audience members tried to silence the man, and at least one media/reporter in front of me took photographs of the man while he (the reporter that is) laughed. Curiously enough (or not), none of the media outlets reporting on this town hall meeting gave any mention at all of his comments.

Democracy is messy, and so is our healthcare (political) system.

Is health care a right or a privilege, and why? That is a question I asked a class of nursing students today. It’s a good question for all of us to consider. And, as one of my students pointed out today, really pay attention to that ‘why?’ at the end. Whatever our political and other beliefs, we need to question our own assumptions.

Speak out. And, for those of you with summertime reflective writing time to be had, I highly recommend you write and submit a 40-400 prose piece on the topic of Healthcare On the Line to Pulse: Voices from the Heart of Medicine.  

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