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.)
These dark, uncertain times demand our full attention, compassion, and capacity to endure beyond what we previously thought we could endure. And by this I do not mean passive suffering or some sick, masochistic hair-shirt sort of endurance. Nor do I mean resilience, the saccharine notion that the human body, the human psyche, and even entire communities (or countries) can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience?
Paul Farmer, physician and global health expert, reminds us that, “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (1)
Trauma never happens in isolation. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process.
Resilience, either from an individual or a community (or country as we are now facing), even if it were possible, would it be desirable? If most traumas, most disasters, are at least partially caused by and certainly compounded by social (in)justice issues, do we want to return to normal, to the status quo after our worlds, our bodies, our communities have been shaken to the foundations, have been seared by fire, have been permanently altered and scarred? Skirting close to the danger of glorifying trauma, of feeding an addiction to the pain and suffering so overly abundant in our world, is the recognition that individual and community healing “means repair but it also means transformation—transformation to a different moral state.” (2) And it means enduring, going on, doing what we can individually and collectively to transform the world for the better.
Paul Farmer. “On suffering and structural violence: a view from below.” In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York: Blackwell Publishing, 2004). pp 281-289. Quote is from p. 288.
Veena Das and Arthur Kleinman, “Introduction,” in Remaking a World: Violence, Social Suffering, and Recovery, ed., Veena Das, Arthur Kleinman, Margaret Lock, Mamphela Ramphele, and Pamela Reynolds (Berkeley: University of California Press, 2001), 23. (Quote is from “Introduction” pp. 1-30. Quote is from p. 23)
See also: Arthur Kleinman, “The art of medicine: how we endure” The Lancet. January 11, 2014. Vol 383. pp 119-120.
What helps us—as health care providers, as caregivers, as people, as communities— endure the various traumas and sufferings we’re exposed to indirectly and that we experience ourselves?
Resilience is something that is often cited as an answer to this question. Resilience is a term that has been adapted from engineering to describe the ability of a substance, such as a metal, to return to its previous state after being stressed—the substance is able to bounce back, to return to steady state, to normal. The American Psychological Association definition of resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” Resilience is sometimes referred to as ‘good survival.’
Over the past several decades there has been an explosion of research on resilience, mainly focusing on individual risk and protective factors. The main protective factors are, not surprisingly: 1) the formation of a firm, secure attachment to a parent or caretaker figure within the first few years of life; 2) prosocial behaviors and personality traits, such as empathy, a positive attitude, capacity for forgiveness, and ability to ‘play well with others’; and 3) a sense of personal agency, of being able to act, to do something positive both in the midst and the wake of trauma. The main risk factors are, not surprisingly, the opposite of the protective factors.
Most research on resilience has focused on the individual, is Western-centric, and has increasingly become biologically reductionist, narrowing in on the epigenetics of trauma and resilience, finding individuals and entire communities of people with ‘short alleles’ and DNA methylation—genetic markers of increased vulnerability to the adverse effects of trauma. That these are most often individuals and communities already marginalized by poverty and racism and other socially-constructed vulnerabilities, serves to further label and pathologize people and communities. It marks them as damaged goods. As irredeemably, permanently damaged goods. It typically ignores the mounting research evidence indicating that such epigenetic damage is largely reversible and preventable with appropriate life experiences—with access to appropriate life experiences, including effective therapeutic interventions.
Resilience-building interventions include cognitive-behavioral psychotherapy; therapies focused on building the capacity for empathy and forgiveness; narrative storytelling and other meaning-making therapies; and therapies aimed at increasing social support—social support that includes social touch—the human version of primate grooming. Good touch: a handshake, a peck on the cheek, or a hug in greeting; a hand brushing a shoulder in sympathy; sitting close to a stranger on a bus; washing the feet of people who are homeless, people who are rarely touched in a good way.
This all sounds good, but resilience irritates me. The whole saccharine notion that the human body, the human psyche, and even entire communities can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience? Certainly, I believe that strength-based research and interventions are an important and sizeable improvement over our traditional deficit models so prevalent within health and social services. But resilience has its dark side.
Resilience tends to glorify trauma, and contributes to an addiction to pain and to suffering: What doesn’t kill you makes you stronger. Be the hero of your own life. Cancer saved my life, made me a better person. And Hemingway’s “The world breaks everyone, and afterward, some are strong at the broken places.” It glosses over the fact that trauma and resilience are not equal opportunity affairs, that some people (women, children, people with various disabilities, non-whites, and gender nonconforming people), and some communities (marginalized by homelessness, poverty, racism, and the effects of colonization) are much more likely to be exposed to traumas in the first place, and they have fewer resources to weather and recover from the traumas. It ignores the larger structural inequities, as well as the stigmatizing narratives we place on certain people, communities, and entire impoverished countries. As physician, anthropologist and global health champion Paul Farmer reminds us, “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (p 288)
Trauma never happens in isolation, even if it is a one-time trauma that occurs to one individual, trauma happens within the context of a particular family, community, cultural, social, and time period. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process. If suffering is a universal yet unequal human experience, being able to tell and listen to illness and trauma narratives matters. But it doesn’t stop there. Physician, anthropologist, and expert on illness narratives Arthur Kleinman admonishes us that it is the moral and emotional cores of these experiences that matter much more, including the cores of social suffering that especially affect marginalized people.
Kleinman also encourages us to ask the question, 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.” (p 119)
Note: This is an excerpt from a work-in-progress, Soul Stories, a collection of essays on the role of narrative in health and healing.
Paul Farmer. ‘On suffering and structural violence: a view from below.’ In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York)/ Blackwell Publishing (2004). pp 281-289.
Arthur Kleinman. “The art of medicine: how we endure.” The Lancet. January 11, 2014. Vol 383. pp 119-120.
This week’s New Yorker article by Kathryn Schulz, “The Really Big One”, about my beloved Pacific Northwest’s vulnerability to a devastating mega-earthquake and tsunami, has stirred a lot of debate and fear here in my hometown of Seattle. There’s been a run on the buying of ready-made disaster preparedness kits. Companies doing seismic retrofitting of houses are now booked out almost a year. As the article states, scientists report that we are overdue for a large or mega earthquake (9,0) and tsunami (100-ft) that will kill at least 13,000 people, injure 27,000, displace 1 million people, and destroy two-thirds of all hospitals. Everything west of Interstate 5 will be destroyed.
Currently, despite having the technology to install a sophisticated early-warning earthquake system, we don’t have one and we will have to rely on the “cacophony of barking dogs” to provide us with a 30-90 second warning before the ‘real quake’ hits. (Dogs can hear the high-frequency compression waves that precede an earthquake. Yet another reason to love dogs.)
It is clear that our government entities, businesses, hospitals, schools, fire departments, need to do much more to prepare for this disaster. As individuals we can support legislation to require better community-wide disaster preparedness (and support ways to actually fund these measures). As individuals we can heed the public health disaster preparedness advice and keep adequate disaster kits in our homes, school, and worksites. In a previous blog post titled “Be Very Afraid” (November 22, 2014) I wrote: “Or be at least a little bit afraid: not so afraid that you become paralyzed with fear and not so little afraid that you don’t do practical things to better prepare yourself (and your family) in case of disaster/emergency. Aim for being ‘just right’ afraid.” And I recorded the items I collected to make our family’s disaster/emergency preparedness kit–along with the realization that disaster preparedness is not an equal opportunity affair.
But something I have learned from my colleagues in New Zealand who work on post-Christchurch earthquake recovery efforts, is that an equally important part of disaster preparedness at the community level is promoting community resilience and wellbeing. More closely-knit communities–regardless of economic resources–tend to weather disasters better than others. Several of the Christchurch-area Maori marae (communal, sacred land/communities) organized to take in and provide food and shelter for foreign students and visitors affected by the earthquakes before any official government-sponsored program was able to do that. This isn’t to gloss over the very real socio-economic and racial disparities highlighted by ‘natural’ and man-made disasters. The lessons on this from Hurricane Katrina in New Orleans stand as reminders.
I was somewhat skeptical when I first encountered these bright, up-with-people banners (shown in the photo above) I saw in the midst of the still fresh earthquake devastation in the downtown core of Christchurch in 2014. But as I focused more on their messages, I realized they were all about building individual and community resilience. They are part of the All Right? Campaign, a Healthy Christchurch initiative of the Canterbury District Health Board and the Mental Health Foundation of New Zealand. They based their campaign on the work of the UK-based social, economic, and environmental justice think tank, The New Economic Foundation, which developed the evidence-based Five Ways to Wellbeing (with a Kiwi slant below). Now these are some excellent ways to prepare for the Big One.
Connect… With the people around you. With whanau, friends, colleagues and neighbours. At home, work, school, or in your local marae, church or community. Think of these connections/relationships as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.
Be active… Exercising can make you feel good! Step outside. Go for a walk or run. Cycle. Play a game. Garden. Have a boogie or do some kapahaka. The most important thing is to find a physical activity you enjoy that suits your mobility and fitness. Do it with friends or whanau and you’ll be ticking two boxes… connect and be active!
Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.
Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn Te Reo or how to play an instrument or cook your favourite food. Set a challenge you enjoy achieving. Learning new things will make you more confident as well as being fun.
Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as linked to the wider community can be incredibly rewarding and creates connections with the people around you. Aroha ki te tangata, a Maori saying meaning respect for/goodwill towards others.
New Orleans, Louisiana, French Quarter, May 2014. Part II.
How do people deal with and bear witness to trauma? How have the people of New Orleans collectively chosen to remember Hurricane Katrina?
As I wrote in my previous post “Collective Sites of Memory: New Orleans” (3-28-15), those were some of the questions I was pondering last May as I returned to New Orleans for the first time since Katrina. Having visited–and been disappointed by–the Katrina National Memorial Park in New Orleans, I decided to visit the permanent exhibit “Living with hurricanes: Katrina and beyond” located at the Presbytere Louisiana State Museum in the heart of the French Quarter.
Greeting me in a wildly disorienting way as I entered the main door of the museum building, was the art installation shown in the photos above. Hundreds of ‘floating’ glass bottles with messages curled up inside them, all hanging from the ceiling. Interspersed among the bottles are ghostly blue glass hands, reaching down–or wait! are they reaching up out of the deluge, the person attached to the hand drowning and asking to be rescued? I stood in the middle of the foyer gazing up at the display as the lights surrounding them gyrated from blue to purple to pink to red and back again–trying to figure out which way was up and which was down in this display. Who are the rescuers and the rescued? It felt as if I was simultaneously the rescuer and the rescued—floating in the midst of the primordial sea of life.
The brightly-colored bottle display also reminded me of that uniquely Southern folk art of bottle trees, shown here in a classic black and white photograph by the venerable writer (and WPA photographer) Eudora Welty. The folk belief is that placing bottles on trees away from the main entrance to the house will help to capture and repel ‘bottle genies’/djinn/or ‘haints’—spirits that haunt a place. The bottle trees are thought to protect people and their homes from calamities. Maybe all the pent-up bottle djinn in the New Orleans area had been released by Katrina.
I have the habit of always looking at a piece of art before reading the accompanying information placard, which often ‘explains’ or interprets what the artist is aiming for. I like to experience the art before being told what it is I am looking at (or hearing), and how it should make me feel. But after several minutes of standing in the museum’s foyer gazing at the bottles and light show, I read the placard below:
The “Message of Remembrances” (notice the singular ‘message’ in the title) was next to the official entrance to the Katrina exhibit, with a large sign stating “Resilience.” Oh no, here we go with the official scripted, up-with-people resilience narrative, I thought, as I entered the darkened room.
‘Resilience’ is an oft-used and ill-used term. ‘Bad things happen to good people, but what doesn’t break you makes you stronger.’ I am highly suspicious of resilience and any context within which resilience is mentioned. I put it in the same category with all those ‘redemptive’ novels according to Oprah: catharsis equals a nauseatingly Hallmark Moment.
But, okay, I will attempt to suspend my critical stance and give this museum exhibit on Katrina an honest chance, I told myself.
As I snaked my way through the rooms of the exhibit, I found quite a lot to admire in how the curators had chosen to ‘tell the story’ of Katrina. The first few rooms were dark and immersive, showing billowing smoke from one New Orleans building, next to a display of an ax stored in the attic of a ‘mock’ house (an essential home safety precaution that I didn’t know about–many people in Katrina got trapped inside their attics in the rising water and drowned because they couldn’t cut an escape route through their roofs).
Then I entered the second room of the exhibit, filled with separate displays on ‘ordinary heroes’ (what is an extraordinary hero–Wonder Woman?), hospitals, First Responders, seats from the Superdome (fiasco), samples of emergency cans of water from the Red Cross, and MREs (Meals, Ready to Eat that included little bottles of Tabasco hot-sauce). There was a brief and somewhat sanitized display labeled “Race, Class, and Inequality” with a heavily edited quote from then President George W. Bush. This second room was filled with random flashing lights of red, yellow, and that freaky blue again, echoing the bottle display.
There was quite a lot of content on the effects of climate change, environmental degradation, and engineering mistakes that all compounded the devastation of Hurricane Katrina. Audio-recordings of Katrina survivors played on an endless loop. An African American man, a former resident of the most severely affected Ninth Ward had this to say: “The water in the vast area matched the speed of a second hand of a clock—that was the amount of time it took for that water to rise. I don’t remember hearing it before: a sound like a freight train.” I found his first person testimony both eloquent and haunting, and I listened to the loop several times to make sure I wrote down his exact words.
But one section of the Katrina exhibit has continued to bother me. It takes up the most space in the middle-part of the exhibit, being eight or nine panels, sections of the actual walls in a central New Orleans housing project apartment. The walls preserve the ‘wall diary’ of Tommie Elton Mabry, a 53 year old man (shown in photo below in front of his wall diary/ ‘ledger or graffiti’ as he called it–written with a black Sharpie.) Mabry, who had been homeless ‘since Regan was president,’ stayed in a first-floor apartment in the deserted high-rise B.W. Cooper public housing development in downtown New Orleans. Starting the day before Hurricane Katrina hit New Orleans until two months later when he was forced to leave by the housing authority officials (the building has been torn down).
What bothers me about this part of the exhibit is the unacknowledged ethical issues, power dynamics, and inherent racism and classism. Mabry’s diary entries are written in about a fourth or fifth grade level, include frequent f-bombs, and many of the entries focus on him getting drunk or nursing a hangover. These all highlight negative stereotypes of homeless people, and especially of African American poor people.
In the photo and in several local newspaper articles (see below), Mabry appears to be proud of the fact that his diary is now on permanent display in a museum. But did anyone bother to ask his permission before they preserved his ‘wall diaries?’ Did anyone consider setting up some sort of appropriate payment–or housing fund– for use of his words?
Tommie Elton Mabry died of a heart attack in 2013, at the age of 58. He was still homeless and couch-surfing at the time of his death.
We’re used to hearing the term ‘first responders’ whenever there’s any news coverage or conversations about disaster/emergency preparedness, response, and recovery efforts. And we’re used to seeing images (like the one below) of the typical types of official first responder personnel and their equipment: firefighters, police officers, EMS, Search and Rescue, etc.
This past year I’ve become more aware of the importance of cultural and spiritual first responders, especially in terms of the resilience of communities. Spiritual first responders we may think of as only pastors, priests, imams, and other religious leaders. These people are important sources of solace and ethical guidance. But the cultural and spiritual first responders I’m referring to are the artists and writers within communities who aid in our attempt to make meaning out of catastrophe and chaos, to find ways to not only survive but also thrive in the midst of adversity. They point the way to healing, to the alchemy of remembrance and forgiveness, to resilience.
I’m currently writing an essay ‘Bearing Witness’ about these cultural and spiritual first responders, and about the sticky ethics of witnessing. In the spirit of Thanksgiving, I want to share with you some photos I’ve taken (within the past year) of powerful public artwork in response to the Christchurch earthquakes and ongoing recovery. I am very thankful for the inspiration, perspective and meaning-making they have provided for me. I include the artist’s name when I’ve been able to establish who they are. These are in addition to ones I shared in a previous blog post “Bounce Back” (February 7, 2014) when I was living and working in New Zealand.
I believe this street art mural on the side of a partially-demolished building in downtown Christchurch was part of Canterbury Museum’s ‘Big Walls’ street art project. I haven’t been able to discover who the artist is but I love this arresting piece. Is the hand held up to stop you from coming too close into the danger zone? Is it calling on you to halt your strange disaster walkabout and reflect on what you are seeing, on what you are doing here?
Peter Majendie’s ‘temporary’ installation “185 Chair Memorial” set up in an empty lot in downtown Christchurch, on land where there had been a Baptist Church before the earthquakes destroyed it. (The A-frame white building in the background of this photo is the gorgeous “Cardboard Cathedral” by Japanese architect Shigeru Ban.) Majendie’s original title for his chair installation was “Reflection of Loss of Lives, Livelihood and Living in Neighborhood” and was initially set up in February 2012 for a week to mark the first anniversary of the most devastating Christchurch earthquake. Each of the 185 white-painted chairs represents a person killed by the earthquake. There are desk chairs, bar stools, lawn chairs, stuffed lounge chairs, folding chairs, rocking chairs, children’s chairs, director’s canvas chairs, infant car seats, infant highchairs, and wheelchairs. The sign encourages people to sit quietly in a chair to which they are drawn. “The installation is temporary—as is life,” the artist states.
Love this one! “Weaveorama” is an interactive street art installation by textile artist Hannah Hutchinson. Part of the Gap Filler project in Christchurch, it is a giant public loom with a sign that says “join with us in creating a new city fabric” and encouraging people to add their found or recycled objects. I especially loved the addition of the pink satin bra. Finding a place for appropriate humor and whimsy is important for individual and community resilience.
I’m glad that we got the chance to return to Christchurch for another week. The dust has settled so to speak on the initial shock at seeing the level (and seeming freshness) of destruction in the downtown/CBD Red Zone. This time I think we could begin to see more of the signs (and freshness) of the community resilience in the downtown core.
These are some photos of my favorite bright spots in Christchurch. Roll call in order of appearance:
1) Greening the Rubble and the Gap Filler projects, and specifically their shared space at the Sound Garden made of recycled found post-quake artifacts such as fire extinguishers, battered metal street signs, Aussie flip-flops and the like. As you can see from the photo, the Sound Garden is fully wheelchair and bicycle and stroller-friendly. While I was there a father and his school-aged daughter rode up on a bike and they played and laughed in the garden for at least thirty minutes. From their Kiwi accents and topics of conversation, they seemed to be a local Christchurch family out for a Waitangi Day of fun.
2) Across the street from the Sound Garden are these lovely, otherworldly yet oddly inviting sculptures called Tree Houses for Swamp Dwellersby Julia Morison (Scape Public Art). As Christchurch residents now know all too well, their city is built on a swamp (liquefaction is an ongoing problem). These beautiful sculptures are sending green shoots out towards the sky. What you can’t see from this photo is that each sculpture has a little garden of plants living happily in its crown. An uplifting and happy space for me, especially given the fact that my group of students were bogeying down to their music blaring over loudspeakers at the Dance-O-Mat (another Gap Filler project) right beside these sculptures.
3) The Gap Filler’s Pallet Pavilion. Blue-painted wooden pallets stacked high to make protective walls around an outdoor cafe/bar/performance stage–complete with free wi-fi. While I was there, a very good Latin band was performing to an adoring crowd. The Pallet Pavilion is coming down at the beginning of April. A temporary installation that lasted a few years. Our students volunteered for a while there, wiping down tables (that collect dust from the building and demolition all around them) and watering plants.
4) The Transitional ‘Temporary’ Cathedral built almost completely out of cardboard and designed by the Japanese ’emergency architect’ Shigeru Ban. The very sweet church lady inside the day I visited said that the parishioners loved how light-filled the cathedral is. She laughed and said she doubted they’d want to return to the cold, dark stone cathedrals even if they are repaired. All of the old stone churches I’ve seen around Christchurch sustained extensive earthquake damage and are still closed. I was surprised when she told me that the church was built to last for fifty years. Being in Christchurch though does blur the distinction between permanent and temporary.