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.)

Listen, Carefully

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“Silence” by Johann Heinrich Fussli, 1799-1801

My essay, “Listen, Carefully,” was published today by Electric Literature/Okey-Panky. I love the Okey-Panky tagline, “Literary oddments for busy people.” They state that my essay (or is it really a prose poem?) is a 4-minute read. It includes a link to my 7-minute digital storytelling video of my reading of the piece, accompanied by my photographs.

“Listen, Carefully” is part of my book and digital humanities project, Soul Stories: Voices from the Margins. In “Listen, Carefully” I parse out some of my criticisms of the practice of narrative medicine, as well as the rhetoric of listening—and of silence.

Past Forgiveness: Part 1

DSC02140The following is an excerpt from my book manuscript titled Soul Stories: Voices from the Margins (under review). I’m sharing it here—and now—because I know of at least one young woman out there in the world who probably needs to hear these words. I’ll post a a “Part II” soon.

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In Regarding the Pain of Others Susan Sontag writes of the meaning of images depicting tragedies and traumas. Towards the end of the book she contends, “There is simply too much injustice in the world. And too much remembering (of ancient grievances: Serbs, Irish) embitters. To make peace is to forget. To reconcile, it is necessary that memory be faulty and limited.”

But I wonder if reconciling, if forgiving, is always predicated on forgetting. And, is forgiving always a good thing?

As I began writing this essay, a young white supremacist shot and killed nine black people during a prayer service in a historic black church in Charleston, South Carolina. The day after this hate crime atrocity, the relatives of those murdered came together and gave a public declaration in which they called on the shooter to confess his crime and repent. He was not admitting to any wrongdoing or crime, yet they forgave him for murdering their loved ones. They said that they called on their deeply held Christian convictions to guide them in this matter.

Was their quick and very public forgiveness a form of Christian witnessing, a rebuke to the Devil, to evil in the world? Or was it something else? I realize I am treading on difficult ground here, that being within my white privilege I can never know what the family members of those victims experienced. Of course, there is something admirable and noble in turning anger and vengeance into love and forgiveness. But then that becomes the standard and what if there are relatives of victims who can’t or do not want to forgive the white supremacist murderer?

Forgiveness is a peculiarly Christian thing to do.  Having been raised within an exclusively Christian worldview—with its turn the other cheek, forgive a person seventy times seven, forgive us our debts as we forgive our debtors—I hadn’t realized that other major world religions like Judaism have different views on forgiveness. In Judaism, forgiveness can only be granted by the aggrieved person, and only after the perpetrator has asked for forgiveness and has made both atonement and restitution.

Forgiveness is also a peculiarly female thing to do; it is emphasized in traditional gender roles in Eastern and Western societies. Women are conditioned to be the family and community peacemakers, and forgiving is viewed as an essential part of that role. People who forgive are supposed to “soften their hearts,” release their anger and sense of revenge in nonviolent, nonliteral ways.

Robert Enright, a Catholic psychologist at the University of Wisconsin—Madison, has developed a 60-item Forgiveness Inventory to measure forgiveness, and an 8-step program leading to forgiveness. He has been dubbed “Dr. Forgiveness.” Through his research, he contends that people who forgive lead healthier and longer lives than those who “stay stuck” or “hold on to” resentment and a lack of forgiveness. He advocates the use of the “two chair technique” in counseling someone to forgive. The person sits in one chair facing an empty chair representing the person who wronged them. They tell that person—that chair—how they feel. Then they sit in the second chair, try to see things from the other person’s perspective, and talk things through with the imaginary person until they achieve forgiveness.

There is even an International Forgiveness Day, the first Sunday of August, established by the World Wide Forgiveness Alliance. (It has been changed to October 7th for 2016 for some reason.) The 2015 Forgiveness Day was on August 2nd, and at 2pm on that day people were called “to take two minutes to forgive someone and join over 2 million people in the Wave of Forgiveness.” On their website, they featured photographs and testimonials of the 2015 Heroes and Champions of Forgiveness. Most were women and it seems that most were women of color, a fact I find ironic given the power dynamics inherent in forgiveness.  I took the online 33-item Forgiveness Quiz with questions such as “Forgiveness is a sign of weakness,” and “I believe that revenge is devilish and forgiveness is saintly”—an echo of Alexander Pope’s famous line of poetry “To err is human; to forgive, divine.”

Most of my answers to the quiz questions using their Likert scale were neutral because my real answers to these questions were “it depends.” Nevertheless, my composite score told me I tend towards being a more forgiving person. Even though I think it is a rather silly and oversimplified test—and I question our society’s insistence on forgiveness, especially gendered forgiveness—I find my test result to be comforting. I also find that comfort disquieting.

Summer Reading Challenge 2016

IMG_7812Reading through the recent NYT article “12 New Books We’re Reading this Summer (and 6 Not So New),” with the list of summer reading by their book critics and staff, I was reminded that it is time to come up with my own summer reading challenge book list with a health humanities and social justice slant. Also, I was reminded to come up with a more diverse reading list than the one offered by the NYT. I did  similar list last summer (see previous blog post, Summer Reading Challenge with a Health Humanities/Social Justice slant ( June 2, 2015), with subsequent posts on my reading progress and reviews of the books.

My Summer 2016 Reading Challenge list of fifteen books is mainly composed of books I’ve acquired over the past few months during my cross-country travels, as well as from both the Association of Writers and Writers Programs (AWP) Conference in Los Angeles and the Health Humanities Consortium meeting in Cleveland. Four of the books on my list are truly ‘new’ books and the rest are new-to-me books. Here they are, listed from the bottom up as shown in the photo above:

Happy and thoughtful and humanistic summer reading everyone!

The Health Humanities Consortium

logo-1This relatively new group has provided a breath of fresh air in my life, as they manage to blend a not-overly-stuffy academic grounding with all the passion, creativity, and ‘meaning of life’ that the humanities has to offer. I’ve recently returned from their second annual conference and these both have easily been among the best conferences I’ve ever attended (and being an academic-type, I have been to numerous conferences). Great people doing great and important work to try and humanize health care and health professions education.

From their fresh-off-the press website:

“About: The Health Humanities Consortium is a community of scholars and institutions who work in the humanities and arts to promote, reflect on, and advocate health and health care in the world.”

Source: About

Sick Nurses

V0026904 Florence Nightingale. Photograph by Millbourn.
Creative Commons. Photograph by Millbourn. Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk

Within the profession of nursing, we have a long and distinguished line of sick nurses who write. There was, of course, the mother of all sick nurses, Florence Nightingale, who, after the Crimean War, took to her bed with a mysterious illness that lasted for the last thirty years of her life. It was during this time that she wrote prolifically–letters and missives to the War Office, health care and social reform reports, and her now famous book Notes on Nursing.

Was her illness neurasthenia (nervous exhaustion, an actual medical diagnosis until the 1930s)? Was it a clever ploy to draw sympathy and support for her zealous cause of reforming nursing, hospitals–indeed, all of health care? Was it a clever ploy to have more protected time for writing and reflecting on the state of the world in need of her reform? Was it–as was taught to nursing students as late as the 1970s–the effects of tertiary syphilis? Was it–as current medical historian Philip A. Mackowiak postulates–a combination of bipolar disorder, PTSD from the horrors of the war, ‘Crimean fever’/brucellosis contracted from contaminated milk while in Turkey–and finally, the most likely cause of her death at age 91, Alzheimer’s Disease? (From his book, Diagnosing Giants: Solving the Medical Mysteries of Thirteen Patients Who Changed the WorldOxford UP, 2013.)

As Lytton Strachey puts it in his wonderfully intelligent short biography of Florence Nightingale in Eminent Victorians (Bloomsbury Press, 1918): “Her illness, whatever it may have been, was certainly not inconvenient. (…)  Lying on her sofa in the little upper room in South Street, she combined the intense vitality of a dominating woman of the world with the mysterious and romantic quality of a myth.”

Lady with the Lamp. Ministering angel. Pious Christian woman relieving suffering in the world. Nursing as a religious calling. These are the nursing myths we still live with. The nursing myths we as nurses–and especially as nurse writers–still perpetuate.

That’s what I kept thinking today as I read nurse and poet Cortney Davis‘ new book When the Nurse Becomes a Patient: A Story in Words and Images (The Kent State UP, 2015). Her book is part of the ‘Literature and Medicine’ series that includes the wonderful short story collection What’s Left Out by physician writer Jay Baruch. (Baruch’s book also happens to have one of my favorite book cover designs–check it out here.)

Cortney Davis is a seasoned nurse practitioner and a talented poet. I especially like her poem “What the Nurse Likes” included in the now almost classic book, Between the Heartbeats: Poetry and Prose by Nurses (edited by Davis and Judy Schaefer, U of Iowa Press, 1995). But over the past decade or so, Davis’ work has become stridently religious (Catholic) and proselytizing (anti-abortion among other matters). The fact that her latest book was published by a reputable (and secular) university press, and has just received the Book of the Year Award (for the category ‘Public Interest and Creative Works) by the American Journal of Nursing combined to make me look forward to reading the book.

When the Nurse Becomes a Patient tells the story–through pictures and words–of her experience with life-threatening complications of what was supposed to be routine day surgery in 2013. She had an extended hospital stay and then convalesce at home. Davis, a life-long writer, found that writing had ‘left her’ but that she was able to paint images of her illness experience.

The print version is a children’s picture book size and the printing quality of Davis’ twelve paintings depicting her illness is quite good. Favoring Davis’ poetry over her prose, I was disappointed to find that it was plain prose descriptions that accompanied each full-page image of the corresponding painting. Two of the prose/painting combinations, “On a Scale of One to Ten” and “My Husband Cares for Me Tenderly” are both quite powerful and effective at evoking important aspects of her individual-yet-universal illness experience. But most all of the remaining ten prose/paintings were over-the-top religious, what with Dark Nights of the Soul (parts one a two no less), last rites (with a priest figure), and and “Angel Band” with–yes–nurses as angels and the figure of a nun in full habit by the patient’s bedside. And, of course, there was the requisite redemptive suffering bit in “I Offer My Suffering.”

Davis, like everyone else, is free to have and write about their own personal religious beliefs. People who are ill are typically driven to face existential crises, which can lead them to deepen (or abandon) a personal faith. But books like this make me despair of nursing ever breaking free of its overly-pious Victorian roots. It’s something that I suspect even Florence Nightingale herself (pre-cognitive decline) would have wanted for nurses and for the profession of nursing. We are not angels and suffering is not redemptive.

Carrying Stories: Beyond Self Care

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Girl with Balloon, street art by Banksy. This one found at intersection of K-Road and Queen Street in Auckland, New Zealand. Photo credit: Josephine Ensign/2015.

What to do with difficult stories? Stories of refugees, victims of mass shootings, of hate crimes, of rape, of torture victims, of people dying alone and unnoticed ?  It all gets overwhelming and depressing to hear or read these sorts of difficult stories, to carry them in our hearts, to bear witness to so much suffering in the world.

Of course, for many fortunate (perhaps unfortunate?) people, there is the option of tuning out these stories, turning off the news, unplugging from any non-vacuous form of social media. Taking a break from difficult stories.

But what about all the other people who cannot or choose not to disconnect? What about people whose work involves listening to these stories on a daily basis? Frontline health care providers who work with people experiencing trauma (physical, emotional, sexual). First responders. Counselors, mental health therapists, lawyers. Human rights activists. Researchers working on social justice issues. What can they do to, if not prevent, at least deal effectively with, vicarious or secondary trauma? And for those of us who teach/train/mentor students in these roles, how do we prepare students to be able to carry difficult stories while maintaining well-being?

In a previous blog post, “Burnout and Crazy Cat Ladies,” I explored the issue of ‘too much empathy’ and of pathological altruism, linking to some of the (then/2011) current research. After writing that post and some related essays, I began incorporating a new set of in-class reflective writing prompts for soon-to-be nurses in my community/public health course. I used these in a class session I titled “Public Health Ethics, Boundaries, and Burnout.”

The first writing prompt: ‘What draws you to work in health care? What motivates or compels you to do this work?’ And then later in the class session– after discussing professional boundaries (how fuzzy they can be), individual and systems-level risk factors for burnout, and asking them to reflect on how they know when they are getting too close to a patient, a community, or an issue–I gave them the follow-up writing prompt: ‘Referring back to what you wrote about what draws you to work in health care, what do you think are the biggest potential sources of burnout for you? And what might you be able to do about them?’

Feedback from students about this in-class reflective writing exercise and the accompanying class content on boundaries and burnout, was invariably positive. Many of them said it was the first time in their almost two years of nursing education that anyone had addressed these issues. I understand that patient care, electrolyte balances, wound care and all the rest of basic nursing education takes priority, but it makes me sad that we don’t include this, to me what is fundamental and essential, content.

“…people who really don’t care are rarely vulnerable to burnout. Psychopaths don’t burn out. There are no burned-out tyrants or dictators. Only people who do care can get to this level of numbness,” Rachel Naomi Remen, MD reminds us in her book, Kitchen Table Wisdom: Stories That Heal (Riverhead Books, 1996). Something to remember when we are feeling overwhelmed by difficult stories.

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Here are some excellent resources: