Friday, November 30, 2007

Therapeutic Relationships: How (and When) to Say Goodbye?

What do clinical boundaries really mean? Where does a therapeutic relationship end and a friendship begin? When we interact on deep and profound levels with clients/patients over long periods of time---sometimes for years---what does it mean to say goodbye? Is it possible to satisfactorily take one's leave of a long-term therapeutic relationship and feel OK saying "Have a nice life!" as the door slams on your way out

Having just emerged from a psychotherapy appointment wherein I was discussing just these issues, my mind and heart are simply brimming with thoughts and feelings about just such scenarios.

Leaving a job is (almost always) a process of letting go, of relinquishing the past in the interest of a newly forged potential future. When one leaves a workplace, there are the inevitable goodbyes to colleagues, "subordinates", "superiors", and others with whom one shared a relatively large portion of one's waking life. This is no small matter, and such a leave-taking is more often than not fraught with uncertainty, nostalgia, and a tinge of regret. It is an accepted and normal phenomenon that, when one gives notice and begins to prepare to leave a workplace, that workplace will suddenly seem more friendly, more amenable, and more comfortable. It's almost as if the Universe begins immediately to test one's resolve to leave just as one submits one's resignation. How maddening!

For myself, being on a leave of absence has allowed me more than sufficient time to process my decision to leave, and I have already begun the process of considering my patients and colleagues and what those goodbyes will entail. In a recent post, I began to delineate those challenges. As for colleagues, maintaining contact is simple. Phone calls, emails, dinner or lunch invitations, the occasional party or professional gathering---those relationships can be maintained like any acquaintance or friendship. Inevitably, time and lack of frequent proximity will preclude frequent contact, with many of those professional but collegial relationships falling by the wayside over time, some more quickly than others.

Now, when it comes to patients, that is another arena entirely, and a great deal of forethought must be given to a decision to offer to maintain contact following the end of a therapeutic relationship. Of my 80 patients, there are probably thirty with whom I feel a deep affinity and positive mutual regard, so much so that ending those relationships will be emotionally difficult. Amidst that group of thirty there are probably ten people to who I feel an even deeper connection, and saying permanently goodbye would be painful. Narrowing the field further still, there are most likely two or three people with whom I feel an intimate, almost familial bond, and these are the therapeutic relationships which I could foresee morphing into friendships, albeit friendships with strict parameters and severely limited scope.

Considering such an outcome, one must ask certain questions:

-Does the client want continued connection?
-Is the offer of a continuing friendship/connection in the patient's best interest?
-Are you pursuing this friendship out of guilt or true desire for such?
-How will the new boundaries of such a relationship be established?
-How would said individual contact you?
-Will expectations of frequency of contact be considered?
-Why not just say goodbye?

There are dozens of questions to consider, many of which perhaps you, esteemed Reader, could raise (and please do!). This is a conversation worth having!

Those of us in Human Services and the so-called "helping professions" constantly face the issues of boundaries, transference, counter-transference, and projection. When facing the end of a therapeutic alliance, all bets are off and the game becomes simultaneously murkier and much simpler. The path of least resistance? Say "goodbye, nice to know you, have a good life, and thanks for being you". The path of potential complication (but also of richness and authenticity)? "Let's stay in touch and see what our new relationship/friendship is capable of within certain parameters". In all likelihood, most connections made in this way will, like tangential friendships, fizzle out over time. People move, phone numbers change, lives develop through unanticipated twists and turns, address books are lost, and the frequency of contact gradually subsides. Still, the effort was made, and true authenticity was honored.

As Jerome Groopman, M.D. writes so eloquently in his outstanding book, The Anatomy of Hope (and please simply subsitute the word "nurse" for "doctor" as you read):

"There are some patients whom a doctor grows to love. It is a unique type of love, distinct from any other type of love the doctor has experienced before. It moves outside the bounds of the usual doctor-patient relationship; feelings and thoughts are no longer strictly professional and are shared among true friends."

If this area is simultaneously murky and simple, I am certainly still in the murk. And, as I do in many areas of life when I am faced with difficult choices, I remember that age-old adage that I have quoted here on Digital Doorway before: "Don't just do something, sit there." Thus I will sit with these feelings, with this sense of impending and inevitable change, and perhaps, if I am quiet enough, the answer will make itself known.



Thursday, November 29, 2007

When I Am Old

When I Am Old
by Ray Nargis

When I am old I shall wear a ball cap
From the St. Louis Browns
Because my grandfather once played in their farm system,
Or maybe a John B. Stetson hat, three-corner fold,
Four X and black chinos with both suspenders and a belt
And the knees ripped out, not as a fashion statement,
But from work.
And black biker boots and a T-shirt with the slogan
"I'm Working On My Issues."
I'll use a walking stick and not a cane
And have a key ring with about a hundred keys
And I won't know what any of them open and I won't care.

When I am old I'll drink whiskey in the morning
And coffee at night
And laugh and spit and swear wherever I want.
When I am old I'll help Girl Scouts across the street
Even if they don't want to go
And I won't have a car
And I won't have a bike
And I'll walk everywhere.

When I am old I'll have a dog named Sam Peckinpaw
And some summer's morning I'll lock up the house
And old Sam and I will walk over to see one of my sons
Even if he lives two states away.
When I am old I'll tell people exactly what I think of them
And surprisingly, most of the time it really will be good stuff.
When I am old I won't have a TV
And I won't have a radio
And I won't have a computer or a clock or a phone in the house.
I won't read books and I won't read magazines
And I won't read newspapers and maybe, finally
I'll learn something just watching the birds and the weather.

Wednesday, November 28, 2007

Hypnos and His Discontents

Oh, my dear friend Insomnia has come to call once again. Not one hour after laying down my book and closing my eyes, my eyes spring open as if programmed to do so, taking in the dark room with dilated pupils, and leaving me in a state of ambivalence----leave the warm bed and warm body of my love, or attempt to return to the land of Hypnos, willing myself to slumber once again? Most of the advice on insomnia cautions against trying too hard to get back to sleep. Distract the mind, do something else, wait patiently for Hypnos to work his magic, they advise. So I sit up, put on my slippers, and pad quietly to the living room.

Laptop in hand, Brian Eno on the headphones (Discreet Music, if you must know), and some thoughts to transcribe through the brain-fog of fatigue, I sit on the couch and let my mind wander and fingers type. The house is silent.

Interestingly enough, the book I just finished reading this evening----The Family That Couldn't Sleep---is the story of illnesses as seemingly disparate as Mad Cow Disease (Bovine Spongiform Encephalopathy) and Fatal Familial Insomnia, all caused by proteins called prions which, in their apparent malfeasance, cause messy tangles of proteins which lead to neurological deficits and other manifestations of illness, some of which can be fatal. While I have no fears that my own insomnia will somehow bring about my eventual demise, lost sleep is not something to take lightly. Sleep is a healing journey of brain activity and spiritual and emotional renewal which I understand to be crucial to good health and overall well-being. Currently not working, the prospect of a nap tomorrow afternoon at a time of my choosing somehow assuages my concerns as the minutes tick by. It's my party and I'll sleep when I want to (if my body agrees with my desire, of course.)

Until quite recently, something which would wake me from deepest sleep in the cruelest manner was a condition known as Restless Legs Syndrome (RLS). Ridiculously descriptive disease name aside, a drug named Mirapex has proven to be rather miraculous in stemming the tide of RLS. Unfortunately, chronic back pain---altogether unresponsive to medications and all manner of treatments and interventions---wakes me from my slumber most every night and plagues me throughout each day. Sadly, a scheduling faux pas---most likely my own brain's mifiring----led to my missing an appointment for a potentially effective spinal injection today. Thus, a very disappointed me left the sports medicine clinic without treatment this afternoon, the injection postponed (yet again) until next week. "Woe is me", says The Nurse with Chronic Pain as he types away in the wee hours.

And how would this pain and insomnia and restless agitation be experienced in the face of forty hours of grueling work as a nurse? That has been my experience for several years now, and the toll it takes on a body and a mind is no laughing matter. Chronic illness and full-time work are mismatched bedfellows indeed, and these last few years have been an exercise in frustration, perseverance, pain, and the inevitable gritting of teeth.

All of this ruminating is nothing more than the weak writing of an insomniac nurse with various physical and emotional complaints spouting off at one in the morning. Inspiring prose? Hardly. Evocative of tea and sympathy? Doubtful. Self-indulgent? No question. But if one cannot be self-indulgent at 1 a.m., when can one do so?

Thank you for your indulgence, dear Reader. May your sleep be long, uninterrupted, peaceful, and truly a blessing, and may your dreams be healing to your soul. And may Hypnos condescend to welcome me to return to his lair quite soon. As the saying goes, "to sleep, perchance to dream".........







Tuesday, November 27, 2007

Nurses and Hell

Did you hear about the nurse who died and went straight to hell?
It took her two weeks to realize she wasn't at work.

Monday, November 26, 2007

Harm Reduction

Today in Ottawa, a rally will be held in support of Insite, the first supervised safe injection site in North America for individuals addicted to intravenous drugs. A blog specifically devoted to this issue is promoting the rally, requesting that Canadian citizens supportive of this successful harm reduction technique make their presence known in Ottawa today. 

As strange as it may seem to the uninitiated, providing a safe, clean and supervised environment for injecting drug users is in the interest of the safety and health of all citizens. According to the Insite website, rigorous scientific evaluation has shown that supervised injection leads to: reduced use of injectable drugs in public where children can be exposed to such behavior; reduced overdose fatalities; reduced transmission of blood-borne infections such as Hepatitis C and HIV; reduced injection-related infections; and improved public order. 

From my own experience participating in street outreach to IV drug users, teaching regarding clean injection technique, the availability of needle exchange programs, and medical oversight of IV drug use significantly impact public health and actually reduces the economic burden of drug use on the taxpayer by reducing ER visits, avoidable injuries, unnecessary hospitalizations, infection with blood-borne pathogens, and death rates from such behavior.

In terms of the philosophy of harm reduction, we meet the addict where he or she is, and we provide education to reduce the risks incurred through such behavior. We understand that the behavior is harmful, yet we also recognize that many individuals are not ready to address their addiction through treatment, thus we seek to mitigate the deleterious effects of their behavior. In so doing, we demonstrate to the addicted individual that we understand the difficulty of quitting and that we will support him or her in that process according to their readiness to pursue treatment. The trust created through such interactions has been documented to have a greater success rate in bringing addicts into treatment for addiction, as opposed to "tough love" interventions which preach or force a particular set of values upon the target population. 

Form more information regarding the philosophy and practice of harm reduction, The Harm Reduction Coalition's website is an excellent resource. If your community does not allow needle exchange or other harm reduction techniques, consider contacting organizations in your area that advocate for such interventions, and discuss the issue with local and state legislators. 

Addiction is, for better or worse, here to stay, and even the addicts amongst us deserve a chance to stay healthy, be supported, and seek treatment when they are ready to do so. 

Sunday, November 25, 2007

Detoxing from Work

Talking with an acquaintance at a cafe this evening, I mentioned that I'm on a leave of absence from work due to stress and overwork. Her response was, "Oh, so you're detoxing from work?" I didn't have to think about it for more than a moment before answering, "Absolutely. By the way, can I use that phrase?" She nodded approvingly.

Detoxing from work. How apt. How utterly appropriate. When work becomes toxic, one ultimately becomes ostensibly inebriated with stress. And what, pray tell, are the signs and symptoms of such an inebriation? Impaired mental faculties; poor coordination; impaired coping; altered interpersonal relationships; sub-optimal self-care; emotional lability; impaired decision-making; stress-related illness. 
So, when one suffers from chronic inebriation, one must detox, which more often than not translates to a removal of the afflicted individual from the environment, people and triggers which facilitate said inebriation. Thus, I have, in effect, removed myself from my personally inebriating environment (work), separating myself from the people (colleagues and patients) and triggers (patients' neediness and trauma) which exacerbate my stress levels, stress-induced illness, and vicarious traumatization. 
Returning from detox becomes a challenge when one has successfully divorced and separated oneself from the influences which previously caused one such suffering. Returning to the same old environment, people, and triggers from prior to the detox can be a difficult emergence, especially if one's recovery is still somewhat tenuous. At times, the individual returning from detox will decide to eschew the old haunts, avoid the environments and people who triggered his or her previous demise, and establish new patterns and ways of living centered around healthy choices and new paradigms. 
At the end of my leave of absence, I will reenter the fray at work, diving back into the environment that I believe to now be toxic to me. According to the terms of my leave, I must return full-time for thirty calendar days following my detox on the outside. 
So, this begs the question at this point in my recovery from work toxicity: Will those thirty days back on the front lines erase the gains which I will have made during my detox? And, more importantly, will I then decide beyond a shadow of a doubt that it is truly time to go? Stay tuned, esteemed Reader, and Time will surely kiss and tell. 

Saturday, November 24, 2007

Attachment, Anticipatory Grief, and Goodbyes

Faced with returning to my full-time job in mid-December following my six-week medical leave-of-absence, it has become painfully apparent to me that my days there are numbered. With the prospect of a job-share having fallen through, I face a slew of choices vis-a-vis my employment status, and the possibilities, while exciting in their potential, also open up tender emotional areas of attachment and anticipatory grief.

Having worked in my current position for seven years, a great deal of my identity as a nurse has revolved around serving low-income, inner-city populations whose vulnerability to disease and psychosocial dysfunction makes them ripe for our services. An endless well of need and dependence, my group of 80 patients have lived in my brain and heart for all of these years, and my emotional closeness with a number of them makes it most difficult to consider leaving my position for new horizons.

I have practiced nursing in a manner in which "therapeutic use of self" is a frequent technique of connection and teaching, using examples from my own life and struggles with chronic illness and depression as teaching tools and methods of expressing sincere empathy. Such disclosure, as well as my very personalized approach to nursing practice and therapeutic relationships in general, engenders an emotional intimacy that is slightly outside the norm for medical and nursing practice. For this reason, I have become quite invested in the lives and well-being of some of my patients, and I fully realize that this is a potential factor in the eventual development of burnout and compassion fatigue over time. I recently wrote a blog entry about vicarious traumatization, a phenomenon which is more than theory for me. It appears that my patients' trauma and traumatic histories have also begun to trigger my own personal trauma history, further exacerbating my feelings of burnout and compassion fatigue.

With time on my hands during this leave of absence, I have had opportunity to reflect on my relationships with a number of patients, and the notion of saying goodbye and terminating said relationships brings me great pain. As I conjure a mental image of this patient or that patient, I experience a wincing sensation wherein I think, "Oh, no! How will I say goodbye to him/her?" And the thought of each patient of whom I am fond evinces yet another uncomfortable sensation of loss.

This workplace where I have given my all for seven years is like no other I have experienced. United in our mission to serve the poorest, sickest, and most dysfunctional sub-populations, we are also united in a day-to-day feeling of being overwhelmed, of swimming against a steady current of unquenchable need, and of knowing that our collective and individual levels of stress are potentially hazardous. As much as we complain about our patients and their neediness, there must also be an aspect of attachment and addiction to such drama on our parts as well. There must be some secondary gain for us as we slog through the challenges of our days, striving to keep our heads above water in a current which changes directions---and depth---without notice or sympathy for our collective and individual plight. The undercurrent of family and camaraderie under duress keeps us afloat, even on the worst of days.

Within the adjacent inner-city community health center with which we partner to care for our patients---and where our patients receive their primary healthcare---there is a team of doctors with the majority of whom I have developed stellar working relationships. These doctors, all of them very committed to the care of the disenfranchised, poor, and chronically ill, have consistently treated me with a level of respect and professionalism unparalleled in my experience as a nurse. This sentiment is echoed by most of my nurse colleagues, and the learning and teaching which these working relationships engender is priceless. On a first-name basis since the beginning, my opinions and suggestions are taken seriously by these docs, and our discussions are never one-way---rather, there is an exchange of ideas focused on the ultimate goal of improved health and function for our mutual patients, although I frequently do feel that I am left with more responsibility than I can handle. Still, I see that my efforts are recognized and appreciated, and that my opinion is thoroughly and thoughtfully considered. If I am mistaken, it is always pointed out in a gentle and kind way with a goal of teaching and learning which is free from games of power and hierarchy, with few exceptions.

So why leave, you may ask? Why walk away from a situation in which satisfying professional relationships, clinical skill development, and challenging medical and psychosocial situations stimulate my mind, spirit and soul? It is because this level of engagement and deep involvement with extremely needy and often dysfunctional patients over a long period of time has whittled away at my core, slowly but surely damaging my ability to enjoy life outside of my work, causing such levels of stress that my personal quality of life has become diminished. Whether directly related to this job or simply a matter of synchronicity and coexistence , my own constellation of chronic illness, chronic pain, and long-term struggles with major depression are necessitating a change of lifestyle, a ratcheting down of the intensity I experience vis-a-vis my professional life. Perhaps I understand and empathize with my patients so well because of my own chronic illnesses, but because of those personal issues, that empathy, while helpful and useful therapeutically for my patients, is slowly but surely eroding my own ability for healing.

Drawing on my interest in Buddhism, I realize that these sensations and feelings, while sincere and quite real, are a manifestation of attachment. Various attachments arise in relation to possessions, people, relationships, circumstances, and even feelings and sensations. My reluctance to leave my workplace after seven years is, to a large extent, a reflection of a certain level of comfort I have developed, even though that comfort paradoxically coexists with burnout, overwork, and a growing sense of frustration with the intensity of the work and the programmatic dysfunctions of our organization. How to reconcile all of these factors and stay on the same path without incurring further personal damage?

I am at a turning point in my career. There are new avenues of nursing and my professional self which I long to explore, yet slogging away on the front lines of inner-city nursing practice---and the stressors therein---is most likely keeping me from pursuing those new avenues, my energy consistently sapped by the vicissitudes of the ol' 9 to 5.

So, I'll keep thinking, reflecting, meditating on it, and embrace these three more weeks of my leave of absence. Returning to work in mid-December, I fully expect at this point to return with my 30-day notice of resignation in hand. Sad, true, difficult, painful, challenging........necessary. And in the immortal words of Michelle Shocked, "the secret of a long life is knowing when it's time to go".

Friday, November 23, 2007

Black Friday and Buy Nothing Day

Today is Black Friday, the biggest shopping day of the year. Many of us choose to actually boycott shopping on this day as a statement to corporate America that we will not acquiesce to an arbitrary designation compelling us to shop 'til we drop on the day after (American) Thanksgiving, just because they said so. Also known as Buy Nothing Day, activists often choose this day to gather in shopping malls for events such as cutting up credit cards, or forming long conga lines of empty shopping carts at Walmart, clogging the aisles, getting in the way of eager shoppers, and of course, buying nothing.

This year, Adbusters is targeting MTV, who refused to air a Buy Nothing Day ad. From the Adbusters' Buy Nothing Day website:


Action update: MTV, the channel that markets itself to hip youth, has decreed that our Buy Nothing Day public service spot "goes further than we are willing to accept on our channels". Gangsta rap and sexualized, semi-naked school girls are okay, but apparently not a burping pig talking about consumption. If you object to this sort of corporate censorship, why not send them a message now?

We never shop on Black Friday, choosing instead to eschew that activity for staying at home and spending nothing. Does our private boycott really have an effect? Possibly on some less tangible level, but it sure feels good to buck the popular trend. As stated on Wikepedia: while critics of the day charge that Buy Nothing Day simply causes participants to buy the next day, Adbusters states that it "isn't just about changing your habits for one day" but "about starting a lasting lifestyle commitment to consuming less and producing less waste."

In terms of holiday shopping, I am making my annual appeal to the readers of Digital Doorway to consider some options other than the usual American corporate suspects. Some selected websites for "alternative" holiday shopping:

Giveline: forget Amazon.com. Giveline offers millions of products, with each purchase generating charitable contributions to your favorite charity. Gift cards and on-line gift cards are available, the recipient having the ability to choose which charity receives a percentage of their gift.

The Hunger Site
: offers special gifts from around the world which benefit those in need with each purchase

as well as....

The Breast Cancer Site, The Child Health Site, The Literacy Site, The Rainforest Site, The Animal Rescue Site

And not forgetting...

Madre

Best Friends

Mercy Corps

For kids, you can adopt an endangered animal from the World Wildlife Fund or Defenders of Wildlife, and they will send the child a certificate of adoption and a plush stuffed animal representing the adopted creature.

Remember, for those friends and families who have everything, you can also give money to a favorite charity in their name. Many charities and non-profits will send a card to the recipient to let them know that you have donated in their name, or you can simply make a homemade gift certificate telling your loved one about the organization to which you donated.

So, remember----you don't have to line the pockets of corporate America just because it's holiday time. Spend judiciously, shop locally if you can, and consider avoiding toys and items manufactured by cheap labor in places like China and Mexico, where workers are mistreated, environmental standards are lax, and the pay is reprehensibly low. Choose toys and gifts made with durable and natural materials, if possible. Look for items that are not sealed in redundant and wasteful plastic packaging. Spending a few dollars more at a local business can have far-reaching effects, decreasing the ability of malls and Big Box stores to destroy local businesses struggling to remain open on a Main Street near you. At this (and any) time of year, you wield a great deal of economic power in terms of when, how, where (and whether!) you open your purse or wallet. Use your power wisely!

Thursday, November 22, 2007

Thanksgiving Thoughts

On this day of giving thanks (one of my favorite holidays in terms of its overall message), I am also acutely aware of the unequal distribution of wealth both here and abroad, the poverty, genocide, and hunger which run rampant, and the notion that the vast majority of humans on this planet live on less than the equivalent of one US dollar per day.

Amidst our meals of plenty and the cornucopias that overflow our tables on this third Thursday of November, I am also aware that the myth of the first Thanksgiving which is taught to our schoolchildren is just that---a myth. While our children draw pictures of turkeys and Indians and Pilgrims all sitting down to a feast of brotherhood and sisterhood, that history is much more complicated---and contradictory---than we are generally led to believe.

Please find below a lengthy yet informative essay by a schoolteacher of Native American descent who shares his research into the history of Thanksgiving vis-a-vis the education of children and adults.

Even while giving thanks, we can acknowledge that the history of Thanksgiving is contradictory at best, and amidst our well-deserved celebrations we can choose to remember those humans and animals who have suffered, are suffering, and will suffer in the future. This is not meant as a wet blanket on a holiday. It is merely an injection of some difficult realism into a time of year which often finds us (myself included) in a culturally-induced trance of blind and ignorant consumption.


>>>>>>>>>>>>.................<<<<<<<<<<<<

This is a particularly difficult introduction to write. I have been a public schools teacher for twelve years, and I am also a historian and have written several books on American and Native American history. I also just happen to be Quebeque French, Metis, Ojibwa, and Iroquois. Because my Indian ancestors were on both sides of the struggle between the Puritans and the New England Indians and I am well versed in my cultural heritage and history both as an Anishnabeg (Algokin) and Hodenosione (Iroquois), it was felt that I could bring a unique insight to the project.

For an Indian, who is also a school teacher, Thanksgiving was never an easy holiday for me to deal with in class. I sometimes have felt like I learned too much
about "the Pilgrims and the Indians." Every year I have been faced with the professional and moral dilemma of just how to be honest and informative with my children at Thanksgiving without passing on historical distortions, and racial and cultural stereotypes.

The problem is that part of what you and I learned in our own childhood about the "Pilgrims" and "Squanto" and the "First Thanksgiving" is a mixture of both history and myth. But the THEME of Thanksgiving has truth and integrity far above and beyond what we and our forebearers have made of it. Thanksgiving is a bigger concept than just the story of the founding of the Plymouth Plantation.

So what do we teach to our children? We usually pass on unquestioned what we all received in our own childhood classrooms. I have come to know both the truths and the myths about our "First Thanksgiving," and I feel we need to try to reach beyond the myths to some degree of historic truth. This text is an attempt to do this.

At this point you are probably asking, "What is the big deal about Thanksgiving and the Pilgrims?" "What does this guy mean by a mixture of truths and myth?" That is
just what this introduction is all about. I propose that there may be a good deal that many of us do not know about our Thanksgiving holiday and also about the "First Thanksgiving" story. I also propose that what most of us have learned about the Pilgrims and the Indians who were at the first Thanksgiving at Plymouth Plantation is only part of the truth. When you build a lesson on only half of the information, then you are not teaching the whole truth. That is why I used the word myth. Sowhere do you start to find out more about the holiday and our modern stories about how it began?

A good place to start is with a very important book, "The Invasion of America," by Francis Jennings. It is a very authoritative text on the settlement of New England
and the evolution of Indian/White relations in the New England colonies. I also recommend looking up any good text on British history. Check out the British Civil War of 1621-1642, Oliver Cromwell, and the Puritan uprising of 1653 which ended parliamentary government in England until 1660. The history of the Puritan experience in New England really should not be separated from the history of the
Puritan experience in England. You should also realize that the "Pilgrims" were a sub sect, or splinter group, of the Puritan movement. They came to America to achieve on this continent what their Puritan bretheran continued to strive for in England; and when the Puritans were forced from England, they came to New England and soon absorbed the original "Pilgrims."

As the editor, I have read all the texts listed in our bibliography, and many more, in preparing this material for you. I want you to read some of these books. So let me use my editorial license to deliberately provoke you a little. When comparing the events stirred on by the Puritans in England with accounts of Puritan/Pilgrim activities in New England in the same era, several provocative things suggest themselves:
  1. The Puritans were not just simple religious conservatives persecuted by the King and the Church of England for their unorthodox beliefs. They were
    political revolutionaries who not only intended to overthrow the government of England, but who actually did so in 1649.

  2. The Puritan "Pilgrims" who came to New England were not simply refugees who decided to "put their fate in God's hands" in the "empty wilderness" of North America, as a generation of Hollywood movies taught us. In any culture at any time, settlers on a frontier are most often outcasts and fugitives who, in some way or other, do not fit into the mainstream of their society. This is not to
    imply that people who settle on frontiers have no redeeming qualities such as bravery, etc., but that the images of nobility that we associate with the Puritans are at least in part the good "P.R." efforts of later writers who have romanticized them.(1) It is also very plausible that this unnaturally noble image of the Puritans is all wrapped up with the mythology of "Noble
    Civilization" vs. "Savagery."(2) At any rate, mainstream Englishmen considered the Pilgrims to be deliberate religious dropouts who intended to found a new nation completely independent from non-Puritan England. In 1643 the Puritan/Pilgrims declared themselves an independent confederacy, one hundred and forty-three years before the American Revolution. They believed in the imminent occurrence of Armegeddon in Europe and hoped to establish here in the new world the "Kingdom of God" foretold in the book of Revelation. They diverged from their Puritan brethren who remained in England only in that they held little real hope of ever being able to successfully overthrow the King and Parliament and, thereby, impose their "Rule of Saints" (strict Puritan
    orthodoxy) on the rest of the British people. So they came to America not just in one ship (the Mayflower) but in a hundred others as well, with every intention of taking the land away from its native people to build their prophesied "Holy Kingdom."(3)

  3. The Pilgrims were not just innocent refugees from religious persecution. They were victims of bigotry in England, but some of them were themselves religious
    bigots by our modern standards. The Puritans and the Pilgrims saw themselves as the "Chosen Elect" mentioned in the book of Revelation. They strove to "purify" first themselves and then everyone else of everything they did
    not accept in their own interpretation of scripture. Later New England Puritans used any means, including deceptions, treachery, torture, war, and genocide to
    achieve that end.(4) They saw themselves as fighting a holy war against Satan, and everyone who disagreed with them was the enemy. This rigid fundamentalism was transmitted to America by the Plymouth colonists, and it sheds a very different light on the "Pilgrim" image we have of them. This is best illustrated in the written text of the Thanksgiving sermon delivered at Plymouth in 1623 by "Mather the Elder." In it, Mather the Elder gave special thanks to God for the devastating plague of smallpox which wiped out the majority of the Wampanoag Indians who had been their benefactors. He praised God for destroying "chiefly young men and children, the very seeds of increase, thus clearing the forests to make way for a better growth", i.e ., the Pilgrims.(5) In as much as these Indians were the Pilgrim's benefactors, and
    Squanto, in particular, was the instrument of their salvation that first year, how are we to interpret this apparent callousness towards their misfortune?

  4. The Wampanoag Indians were not the "friendly savages" some of us were told about when we were in the primary grades. Nor were they invited out of the goodness of the Pilgrims' hearts to share the fruits of the Pilgrims' harvest in a demonstration of Christian charity and interracial brotherhood. The Wampanoag were members of a widespread confederacy of Algonkian-speaking peoples known as the League of the Delaware. For six hundred years they had been defending themselves from my other ancestors, the Iroquois, and for the last hundred years they had also had encounters with European fishermen and explorers but especially with European slavers, who had been raiding their coastal villages.(6) They knew something of the power of the white people, and they did not fully trust them. But their religion taught that they were to give charity to the helpless and hospitality to anyone who came to them with empty hands.(7) Also, Squanto, the Indian hero of the Thanksgiving story, had a very real love for a British explorer named John Weymouth, who had become a second father to him several years before the Pilgrims arrived at Plymouth. Clearly, Squanto saw these Pilgrims as Weymouth's people.(8) To the Pilgrims the Indians were heathens and, therefore, the natural instruments of the Devil. Squanto, as the only educated and baptized Christian among the Wampanoag, was seen as merely an instrument of God, set in the wilderness to provide for the survival of His chosen people, the Pilgrims. The Indians were comparatively powerful and, therefore, dangerous; and they were to be courted until the next ships arrived with more Pilgrim colonists and the balance of power shifted. The Wampanoag were actually invited to that Thanksgiving feast for the purpose of negotiating a treaty that would secure the lands of the Plymouth Plantation for the Pilgrims. It should also be noted that the INDIANS, possibly out of a sense of charity toward their hosts, ended up bringing the majority of the food for the feast.(9)

  5. A generation later, after the balance of power had indeed shifted, the Indian and White children of that Thanksgiving were striving to kill each other in the genocidal conflict known as King Philip's War. At the end of that conflict most of the New England Indians were either exterminated or refugees among the French in Canada, or they were sold into slavery in the Carolinas by the Puritans. So successful was this early trade in Indian slaves that several Puritan ship owners in Boston began the practice of raiding the Ivory Coast of Africa for black slaves to sell to the proprietary colonies of the South, thus founding the American-based slave trade.(10)

Obviously there is a lot more to the story of Indian/Puritan relations in New England than in the thanksgiving stories we heard as children. Our contemporary
mix of myth and history about the "First" Thanksgiving at Plymouth developed in the 1890s and early 1900s. Our country was desperately trying to pull together its many
diverse peoples into a common national identity. To many writers and educators at the end of the last century and the beginning of this one, this also meant having a common national history. This was the era of the "melting pot" theory of social progress, and public education was a major tool for social unity. It was with this in mind that the federal government declared the last Thursday in November as the legal holiday of Thanksgiving in 1898.

In consequence, what started as an inspirational bit of New England folklore, soon grew into the full-fledged American Thanksgiving we now know. It emerged complete with stereotyped Indians and stereotyped Whites, incomplete history, and a mythical significance as our "First Thanksgiving." But was it really our FIRST American
Thanksgiving?

Now that I have deliberately provoked you with some new information and different opinions, please take the time to read some of the texts in our bibliography. I want to encourage you to read further and form your own opinions. There really is a TRUE Thanksgiving story of Plymouth Plantation. But I strongly suggest that there always has been a Thanksgiving story of some kind or other for as long as there have been human beings. There was also a "First" Thanksgiving in America, but it was celebrated thirty thousand years ago.(11) At some time during the New Stone Age (beginning about ten thousand years ago) Thanksgiving became associated with giving thanks to God for the harvests of the land. Thanksgiving has always been a time of people coming together, so thanks has also been offered for that gift of fellowship between us all. Every last Thursday in November we now partake in one of the OLDEST and most UNIVERSAL of human celebrations, and THERE ARE MANY THANKSGIVING STORIES TO TELL.

As for Thanksgiving week at Plymouth Plantation in 1621, the friendship was guarded and not always sincere, and the peace was very soon abused. But for three days in
New England's history, peace and friendship were there.

So here is a story for your children. It is as kind and gentle a balance of historic truth and positive inspiration as its writers and this editor can make it out to be. I hope it will adequately serve its purpose both for you and your students, and I also hope this work will encourage you to look both deeper and farther, for
Thanksgiving is Thanksgiving all around the world.

Chuck Larsen
Tacoma Public Schools
September, 1986


FOOTNOTES FOR TEACHER INTRODUCTION

(1) See Berkhofer, Jr., R.F., "The White Man's Indian," references to Puritans, pp. 27, 80-85, 90, 104, & 130.

(2) See Berkhofer, Jr., R.F., "The White Man's Indian," references to frontier concepts of savagery in index. Also see Jennings, Francis, "The Invasion of
America," the myth of savagery, pp. 6-12, 15-16, & 109-110.

(3) See Blitzer, Charles, "Age of Kings," Great Ages of Man series, references to Puritanism, pp. 141, 144 & 145-46. Also see Jennings, Francis, "The Invasion of
America," references to Puritan human motives, pp. 4-6, 43-44 and 53.

(4) See "Chronicles of American Indian Protest," pp. 6-10. Also see Armstrong, Virginia I., "I Have Spoken," reference to Cannonchet and his village, p. 6. Also see Jennings, Francis, "The Invasion of America," Chapter 9 "Savage War," Chapter 13 "We must Burn Them," and Chapter 17 "Outrage Bloody and Barbarous."

(5) See "Chronicles of American Indian Protest," pp. 6-9. Also see Berkhofer, Jr., R.F., "The White Man's Indian," the comments of Cotton Mather, pp. 37 & 82-83.

(6) See Larsen, Charles M., "The Real Thanksgiving," pp. 3-4. Also see Graff, Steward and Polly Ann, "Squanto, Indian Adventurer." Also see "Handbook of North American Indians," Vol. 15, the reference to Squanto on p. 82.

(7) See Benton-Banai, Edward, "The Mishomis Book," as a reference on general "Anishinabe" (the Algonkin speaking peoples) religious beliefs and practices. Also see Larsen, Charles M., "The Real Thanksgiving," reference to religious life on p. 1.

(8) See Graff, Stewart and Polly Ann, "Squanto, Indian Adventurer." Also see Larsen, Charles M., "The Real Thanksgiving." Also see Bradford, Sir William, "Of Plymouth Plantation," and "Mourt's Relation."

(9) See Larsen, Charles M., "The Real Thanksgiving," the letter of Edward Winslow dated 1622, pp. 5-6.

(10) See "Handbook of North American Indians," Vol. 15, pp. 177-78. Also see "Chronicles of American Indian Protest," p. 9, the reference to the enslavement of King Philip's family. Also see Larsen, Charles, M., "The Real Thanksgiving," pp. 8-11, "Destruction of the Massachusetts Indians."

(11) Best current estimate of the first entry of people into the Americas confirmed by archaeological evidence that is datable.

Wednesday, November 21, 2007

Thanksgiving and Darfur

Dear Reader,

Make Thursday's Celebration Meaningful

Will you include the people of Darfur in your Thanksgiving celebration?

Click here to get started.

Thanksgiving is a very special day for me and my family. We use the time to reflect on all our blessings, appreciate being together, and reach out to those who are less fortunate.

So it probably comes as no surprise that we will be including the people of Darfur in our Thanksgiving celebration this Thursday.

Will you join me in devoting a few minutes of your Thanksgiving celebration to help the people of Darfur?

Click here now to include the people of Darfur in your Thanksgiving this Thursday.

All you have to do is take a moment to share the story of the people of Darfur and hand out a simple petition for your guests to sign.

You'll start by spending a few moments explaining the crisis to your guests (you can download a short overview of the situation to read from if you'd like) and then pass around a printed petition to President Bush and U.N. Secretary-General Ban for your guests to sign.

I hope you'll join me and my family in taking advantage of this opportunity for reflection, thankfulness, and togetherness to help raise awareness about the urgency of the situation in Darfur.

Click here to get started now by downloading the materials you'll need to include the people of Darfur in your celebration.

I'd be remiss if I didn't take this chance to thank you for your commitment to the cause. And I'm not alone. The House of Representatives voted unanimously a few weeks ago to commend the work that Darfur activists worldwide have done to raise awareness of the genocide.

Thank you again for all of your hard work.

Happy Thanksgiving from all of us at the Save Darfur Coalition.

Best regards,

Colleen Connors
Save Darfur Coalition

P.S. Looking for a meaningful holiday gift? If so, click here to visit the Save Darfur Coalition's online store to browse our selection of t-shirts, wristbands, and much more. Our merchandise is the perfect way to give a gift to someone you love and help people in need at the same time.


Donate to Help Save Darfur
Help build the political pressure needed to end the crisis in Darfur by supporting the Save Darfur Coalition's crucial awareness and advocacy programs. Click here now to make a secure, tax-deductible online donation.

Tuesday, November 20, 2007

Back to the Drawing Board, Wherein the Heart and Mind Discuss the Future

Back to the subject of my (currently non-existent) work-life, although the job-share position was ostensibly approved by the powers that be, the nurse practitioner with whom I was planning to share said job has accepted another position. Thus, the job-share is now defunct, and a vast blank drawing board appears on my horizon. Yikes.

So, when faced with a blank drawing board, what does one do? At first, nothing. The blank space is kind of nice, isn't it? See how the light reflects? Notice how that blank space is one upon which any number of potential futures can be projected? Why don't we enjoy it for a while?

But then the Mind in all its glory jumps in, grabs some (thankfully erasable) markers, and goes to town.

"So," the Mind says. "We have Option 1: return to full-time job as planned, and decide to stick it out for another 6-12 months. See all of the gains and stress reduction from the leave of absence erased in a matter of weeks. Hmmm. Maybe not such a good choice." The Mind looks puzzled.

"Well, then," says the Mind. "Option 2 seems better: return to work for the required 30 days, close up shop, say our goodbyes, terminate with patients and colleagues, and skedaddle asap, no looking back. Not a bad scenario, if I do say so myself." Some skeptical interest is perceived.

"Or how about Option 3, perhaps?" asks the Mind hopefully. "Offer to work per diem for old employer after fulfilling 30-days of full-time work in order to fulfill leave-of-absence obligations. String together several other per diem positions---one of which is quite close to home, actually---and have a renewed sense of professional invigoration? Let "The Mrs." carry the health insurance benefits, and take this golden opportunity to cut loose from the 40-hour grind! Work when you want to---some weeks will be extra heavy, others can be quite light. What freedom! What a concept!" The mind smiles.

Then the Heart steps up to the plate, chiming in. "Oh, God! All of those patients with whom we have cultivated intimate working relationships for seven years! How would we say goodbye? How would we terminate? What would it do to them? To my colleagues? To the workplace? How can I handle so many goodbyes?" The Heart wrings its hands.

The Mind rests a reassuring hand on the Heart's virtual shoulder. "Look here, cousin. Don't get so worked up. People leave jobs all the time, even ones in which long-term therapeutic relationships have been nurtured." The mind smiles reassuringly as the Heart looks dubious.

"We all have to say goodbye and move on at some point," the Mind continues. "Patients know that clinicians come and go. It's part of the process. Perhaps your leave-taking will cause some of them to become more self-sufficient, more empowered. Just imagine the relief you would experience when you released yourself from the responsibility you feel for those eighty people and their well-being!"

The Mind and the Heart sit in silence for a while.

"Y'know," says the Heart. I need some time to consider these scenarios. It's just too much to process today."

"I understand," says the Mind. "Change is always hard. Take your time, enjoy the rest of your leave-of-absence, and know that this is all happening for good reasons. Remember that drawing board? We can leave it blank for a while."

"Thanks," says the Heart. "I can only take in so much change at one time. It was enough to accept a six-week leave-of-absence. Let's clean the basement, then we can make dinner and watch a movie."

"It's a deal," says the Mind. "We'll put the drawing board in the corner for now. Let's tackle that basement."

Monday, November 19, 2007

Of Heroes, Parity, and Economics

Last night's post only scratched the surface of the culturally accepted norm dictating that mental health is not on par with physical health when it comes to one's needs for rest and rejuvenation---especially where work is concerned.

Work is, for better or worse, part and parcel of our lives, a veritable necessity for putting food on the table and clothes on our backs. As we moved out of an agricultural society into an industrial---and eventually technological---society, it obviously became necessary for an astronomical number of individuals to become workers who performed duties under the auspices of companies and corporations which held our livelihoods in their hands. Granted, an agrarian society is no panacea---share-cropping and slavery are excellent examples of that scheme's miserable failings---yet the industrial age brought with it abuses and restrictions on individual freedom which, while not necessarily slavery in name, certainly have kept many segments of society in quite similar and dire economic straits.

So, when one has chosen to enter a field of work in which the vagaries of the economy and the edicts of one's employer shape one's destiny, there is a certain amount of freedom that is abdicated. That said, even the self-employed feel that they too must abdicate some freedoms in the face of restrictive tax codes and the high cost of health insurance and healthcare.

For myself, I have chosen to enter the "Medical Industrial Complex", to riff on a phrase originally popularized by Dwight D. Eisenhower in 1961. Within said Medical Industrial Complex, a hierarchy exists, similar to the hierarchies within other disciplines and professional societies. The members of such systems are rewarded for their work based upon algorithms which take into account such notions as experience, education, applicable skills, and other factors which make one a candidate for the assignment of various tasks and responsibilities.

As I stated in yesterday's post, certain segments of society are held in higher esteem than others, earning astronomically higher salaries and benefits than those of us who slog away in blue-collar, "pink-collar" and even many white-collar positions. Most of us would agree that celebrities---including many actors, some entertainers, as well as many professional athletes---receive remuneration for their efforts which far seems to outstrip the relative value and social import of their (cultural and economic) contributions to society. CEOs are another story, and the scale of their remuneration is also sorely out of balance (think Ken Lay, may his soul never rest).

I stated yesterday that the hypothetical baseball player who experiences occupational stress could be pretty certain that his salary---often in the millions, or at least hundreds of thousands---would not suffer in the face of a leave of absence for reasons related to stress.

In my post, I compared myself to that stressed-out baseball player. Let's imagine that I was a nurse who was experiencing incredible levels of stress and burnout by caring for the destitute, chronically ill, and elderly who live in that baseball player's hometown. Maybe several members of his extended family---saddled with substance abuse, mental illness, or other disabling medical conditions---were actually on my caseload. When I decide that I need to take a leave of absence due to stress related to my work, why is it that I---a person providing essential services related to the health, well-being and survival of members of that baseball player's family and community---must do so without pay and with risk of economic hardship, while the baseball player (who essentially swings a piece of wood at a leather ball and catches balls hit by others with the same piece of wood) rests on his laurels and fat bank account, taking a break from his on-the-job stress on Maui? What is wrong with this picture?

Teachers, nurses, police officers, EMTs, substance abuse counselors, social workers, senior center directors, outreach workers, AIDS workers, hospice counselors, homeless advocates, housekeepers, medical assistants, home health aides, daycare workers, laborers----we all experience on-the-job stress, yet it seems only the rich and famous can have respite without negative economic consequences. The families of people in the military live on food stamps in decrepit barracks for the enlisted, yet we say we "support the troops". Again, what is wrong with this picture?

Our measure of "heroes" is askew. Who truly are the heroes? Who should be celebrities? Where are the trading cards of famous nurses and home health aides? When will substance abuse outreach workers have their day? Something is wrong in a culture wherein those who care for the dying must themselves struggle to survive. This is an emergency of priorities, one for which parity and balance seem far beyond reach.

In essence, the true heroes go unsung, and the make-believe heroes take home the prize.

Sunday, November 18, 2007

Injured Soul? You're On Your Own

Recently, an anonymous commenter on Digital Doorway responded to a post I wrote about nurses and stress. He or she wrote the following:

"One major reason why nurses are stressed is because hospitals are understaffed. Management has been able to get away with this understaffing because they don't have to pay for workload-related chronic stress injuries.

"This is discrimination against psychologically injured workers who succumb to excessive WORKLOAD by getting depression or other chronic stress diseases.

"The hard-working employee who sustains a mental injury due to overwork is left without compensation which means they usually then go through a downward spiral of bankruptcy, loss of home, loss of pension and all the further stress that goes along with poverty.

"No wonder we have a health care worker crisis!"

The commenter makes some salient points. Taking my circumstance into consideration, seven years of working with trauma survivors and giving my all to the care of vulnerable individuals has led me to make a decision to take six weeks of unpaid leave in order to collect myself and heal. Why, within this society, are individuals serving the poor, ill and traumatized left to their own devices when it comes to recovering from providing such a public service? Why must burned out teachers and nurses take unpaid leave and use up their personal savings at a time when their service has exacted a psycho-emotional toll on their health?

Now, to draw an apt comparison, if a professional baseball player experienced undue stress and psychological trauma from the vigors of the season's play, would he need to eschew his multi-million dollar salary in order to take a six-week leave to clear his head and regain balance? Would he be forced to use his savings to pay his bills and care for his family while he recuperates? Would some portion of his astronomical salary be withheld? That baseball player, handsomely compensated for his work (which, in my mind, bestows precious little benefit on humanity), will have little difficulty making ends meet while he rests and recuperates.

Furthermore, as an individual appreciated and respected far above the nurses, social workers, factory workers and teachers who are truly a part of the backbone of the society, the athlete in question will have no fear of income loss as a result of his temporary disability. In fact, a guest appearance on Oprah or a Newsweek expose on the psychological stresses of professional sports would most likely be in order. Our athlete suffers in ways which may actually enhance his career.

On the other hand, take a burned-out nurse like myself and consider my options. While I may have the Family Medical Leave Act to allow me up to 12 weeks unpaid time off, short-term disability insurance does not allow for disability for mental health or substance abuse. In fact, many long-term disability insurance policies also exclude a mental health benefit. Parity for those suffering from mental health-related injury are basically left out in the cold.

The conundrum is thus: if I injured my hand at work caring for a patient, workers' compensation would be a no-brainer. But if I injure my soul at work? I'm on my own.

Saturday, November 17, 2007

Job-Share Ahoy!

Well, well, well. It looks like my workplace has conditionally approved a job-share for myself and a Nurse Practitioner colleague following the end of my medical leave of absence. Suddenly, the future looks a whole light brighter.

What does this new reality mean for the earnest nurse who is ever-so-steadily recovering and recuperating from acute burnout, vicarious traumatization, and compassion fatigue? The true meaning of this new reality is multifaceted. Initially, it means that I will no longer carry the emotional, psychological, and clinical weight of some 80 patients on my own shoulders. Instead of a caseload of 80 for which I am solely responsible, I will share a caseload of patients with a very competent Nurse Practitioner of whom I am exceedingly fond. I will be in the office three days per week, and she will be in the office the other two days. With our excellent rapport, open communication, and superb documentation, we will bear this load together, neither of us slogging through the dreaded five-day week. We will meet for lunch once a month to discuss cases, talk by phone, communicate by email, and otherwise work as a well-oiled clinical nurse-machine, free of the burnout born of the forty-hour week.

I acknowledge that I am lucky to be able to either 1) afford to pay a pro-rated increased rate for my health insurance as a part-time employee or, 2) take part in my wife's health plan under the auspices of her place of employment. With health insurance being one of the major factors for many workers staying in jobs which they dislike or cause them undue stress, I realize that I am privileged in having choices vis-a-vis my healthcare and insurance.

As far as generating income, I also realize how lucky I am that, as a registered nurse, the ability to earn money on a per diem basis is one which makes the nurse a hot commodity in the current job market. With two per diem positions already in my employment portfolio---one with a visiting nurse agency and the other at a urban community health center) this part-time nurse can choose to earn extra money one week and slouch around the house the next. What better burn-out prevention could there be?

Taking a leave of absence was a leap of faith which was initiated by my wife (with only a mild threat of divorce) and embraced whole-heartedly by me when I realized that there was no other way for me to regain my emotional balance. With chronic illnesses slowly overtaking my previous state of relative good health, we both acknowledged that something had to give (and I had already "given at the office", so to speak).

Now, as the layers of stress begin to unravel after two weeks' leave, I now face the next four weeks of leave with a desire for further healing and recuperation. With part-time employment and brighter prospects at work, perhaps my life is truly turning around.

Friday, November 16, 2007

Trouble in Serbia

A report released this week by Mental Disability Rights International demonstrates that children and adults in Serbian psychiatric facilities are living in squalid and unhealthy conditions, with patients frequently physically restrained for years at a time, often in their own excrement. With poor sanitation and common communicable diseases inadequately controlled, patients within the Serbian psychiatric healthcare system are suffering in a potentially unparalleled manner. Taking into consideration the extent to which American psychiatric patients and consumers of mental health services feel rightfully disenfranchised within our system here in the US, the atrociousness of care in Serbian facilities is "tantamount to torture" according to the MDRI report.

Although the Serbian government was quick to point out the gains which the country has made in the care of the psychiatrically disabled since 2000, there is no denying the extent of the abuse and neglect being perpetrated in a country vying for entrance into the European Union. To quote from the MDRI website:

" 'These are Serbia's most vulnerable citizens. Thousands confined to institutions are subjected to inhuman and degrading treatment and abuse. Children and adults tied down and restrained over a lifetime is dangerous and painful treatment tantamount to torture - clear violations of the European Convention on Human Rights,' said Attorney Eric Rosenthal, Executive Director of MDRI and an expert on human rights law. ' We call on the government of Serbia to stop these abuses immediately and to respect the human rights of all people with disabilities,' concluded Rosenthal."

Reports by various news organizations all point to the documented facts that children and adults under care in Serbian facilities have suffered---and continue to suffer---greatly under the current system of care.

Watching the video footage from the MDRI website (not for the faint of heart) drives home the reality not fully expressed in words: physical restraints, straight jackets, overcrowding, understaffing, lack of proper sanitation and hygiene, lack of positive stimulation, obvious neglect and barbaric practices, all underscore a nightmarish reality reminiscent of Orwell's and Dickens' worst visions of humanity gone wrong.

Working with vulnerable populations here in the US, one realizes that in many poorer countries where healthcare is decades behind in development, nightmare scenarios still reign. The cynic might ask why we should even worry about disabled children in a country where we have little economic interest. I would respond that how the vulnerable are treated anywhere in the world is a reflection on humanity as a whole, and as the world itself grows ever smaller, our neighbor's plight is never truly separate from our own. If the command to "do unto others as you would have them do unto you" still holds any meaning, then a child in Serbia is no less in need of respect, dignity and love than children everywhere. The MDRI report is an important document, and one would hope that its effects will ripple far beyond the borders of Serbia, stimulating self-reflective assessment of the care of vulnerable people everywhere.





Thursday, November 15, 2007

Early Morning Musings

5:30 am---woken by back pain, restless and uncomfortable. I had acupuncture yesterday for the fourth week in a row, and despite the application of specific needles for back pain, there is no relief (although I have a deep, deep restorative sleep on the table each time). My mood has been very uplifted, although the acupuncture is simultaneous with my leave of absence from work, so it's difficult to parse out what is the true cause of these emotional shifts for the better. Anyway, does it even really matter?

Last night, we went to the local university to see a few more short films on the genocide in Darfur. As an individual, I still feel somewhat powerless in the face of such a human travesty, but I blog about Darfur regularly, sign petitions, boycott Chinese products to a large extent, call my legislators, and get involved however and whenever I can. How can this happen on our watch? Hatred and intolerance and greed are the great failings of the human condition.

Walking by our local radical collectively-owned bookstore, I picked up a copy of "His Holiness The Dalai Lama, Path of Wisdom, Path of Grace: A Personal Conversation" by Felizitas Von Schoenborn. For me, The Dalai Lama is one of the greatest embodiments of compassion on the planet at this time. His seemingly lighthearted and heart-centered approach to the human predicament belies the deeply rooted compassion and grace which are the underlying modus operandi of his life's work. He is someone I venerate without reservation, and I try to embody his teachings in my own humble and imperfect way.

The struggles of back pain, chemical sensitivity, insomnia, financial concerns, and the upkeep of home, hearth and professional life all seem to pale in the face of the suffering of those in Darfur, Iraq, Afghanistan, Palestine, Niger, numerous American inner cities, and other troubled areas of the world. Still, one must approach one's own life and accept its conditions, act sanely to correct those conditions if needed, simultaneously attempting to better the lives of others while never losing sight of one's own relative privilege. Life is a challenge from the start, and suffering seems inevitable. Were it not so, would we even be capable of appreciating that which we do have? As Modest Mouse have so recently sung:

"As life gets longer
it also feels softer
and it feels pretty soft to me;
and if it takes shit to make bliss
then I feel pretty blissfully
If life's not beautiful without the pain
well I'd just rather never see beauty again."

Wednesday, November 14, 2007

Nurses and Stress: A Rant

Thanks to a comment on yesterday's post, I was recommended to read this article on stress and healthcare workers. Brief and to the point, the article elucidates that Canadian "nurses, doctors and lab technicians have the highest levels of stress related to their jobs" of all interviewees, with 45 percent reporting that there work was "quite" or "extremely" stressful.

The International Labor Organization has identified nursing as an industry with relatively high levels of stress and burnout. In identifying the sources of stress in nursing, they elucidate thus:

"The role of nursing is associated with multiple and conflicting demands imposed by nurse supervisors and managers, and by medical and administrative staff. Such a situation appears to lead to work overload and possibly to role conflict. One form of such conflict often mentioned in surveys of nurses relates to the conflict inherent in the instrumental and goal-oriented demands of "getting the patient better" and those related to providing emotional support and relieving patient stress. Role conflict of this kind may be most obvious when dealing with patients who are critically ill and dying. Indeed, one of the areas of nursing that has attracted particular attention has been critical or intensive care nursing. Health care is also a sector which suffers a high rate of violent behaviour (see our pages on
violence at work).

"Many studies on stress in nursing have attempted to measure, or have speculated on, the effects of such stress on nurses’ health and well-being. There appears to be general agreement that the experience of work-related stress generally detracts from the quality of nurses’ working lives, increases minor psychiatric morbidity, and may contribute to some forms of physical illness, with particular reference to musculoskeletal problems, stress and depression."

Hmmmm, says the nurse on medical leave of absence.

In South Africa, stress has been identified as the major cause of a nursing shortage in the setting of HIV/AIDS care. The BBC reported earlier this year that stress was harming nurses' sex lives, causing nurses to smoke more, and that stress-related absences from work costs the British National Health Service more than 300 million pounds per year.

Many nurses complain about frozen wages, lack of clinical supervision, increasing nurse-patient ratios, and rapidly shrinking benefit packages. While loss of benefits and frozen wages are ubiquitous across the general workforce (unless you're a CEO, member of Congress, movie star, or professional athlete, of course), nurses face other stressors which are singular to their profession. Workers in other professions also naturally face challenges typical to their careers and workplaces, and each of us can truly only speak from our own work experience.

We simply have to face the facts. Americans (and workers in other countries, as well) work too hard, earn too little, have paltry time for vacation and leisure, and are expected to marry their jobs to a degree never before expected in the history of labor. Unions have slowly been dismantled and vilified over the last century (especially here in the US), and healthcare benefits have crumbled, leaving many of us paying higher premiums and copayments for office visits, procedures, and medications. With housing costs and fuel costs through the roof, our paychecks have less buying power than they used to, and those of us in the middle class and working class are left to pick up the crumbs left behind by the 1 percent controlling the wealth.

Are nurses stressed? Of course we are. We earn moderate incomes within a high-stress industry where workloads have exponentially increased and benefits faltered. Retirement seems less than certain, the economy continues its volatile course, and the healthcare industry asks more and more of us without offering any further compensation. Still, I never regret my career choice, and have even encouraged others to walk this path. Nurses are always needed, work is generally easy to find, and when the economy hits bottom, we will still be irreplaceable, since illness never takes a holiday.

So, what's an earnest nurse to do, you ask? Dedicated to my chosen career, I take a few weeks to reassess my options, care for my body and mind, soul and spirit, and plan to reenter the fray with---perhaps---a hopeful and newly-minted outlook and approach. I have been ravaged by the effects of stress and vicarious traumatization, and I now attempt to reconstitute myself during this brief hiatus. I consider myself both lucky and blessed, and pray for my nursing brethren who are unable to afford the luxury of such self-care. May we all be free from suffering.




Tuesday, November 13, 2007

Open Heart---An Appreciation

I have a predilection for reading books about medicine and nursing, and nothing pleases me more than discovering yet another satisfying or thought-provoking read, of which there have been many, and of which I fully expect hundreds more such experiences.

Apropos of such literary leanings, today's praise report involves Open Heart: A Patient's Story of Life-Saving Medicine and Life-Giving Friendship by Jay Neugeboren. The author is best known for his book Imagining Robert, the story of his brother's struggles with mental illness and the burdens born by the families of individuals thus afflicted.

Open Heart tells the story of Mr. Neugeboren's experience as a man of more than sixty years of age, who, in excellent and athletic physical condition, experiences symptoms which go misdiagnosed for months, eventually leading to emergent quintuple-bypass surgery which saves his life. In the process of telling his story, the author not only communicates wonder over the technological developments which contributed to his survival. Mr. Neugeboren delves deep into the psyche of lifelong friendship, its importance to quality of life, and the challenges faced by the patient who confronts an often splintered and impersonal healthcare bureaucracy. His insights into the world of medicine, doctor-patient relationships, as well as his relative position as a upper-middle-class author whose well-heeled and educated childhood friends---all of whom are doctors, by the way---contribute to his well-being through their advocacy, professional connections, and knowledge.

There are many ironies addressed in Open Heart, not the least of which is the notion that, even given his relative privilege and access to high quality healthcare, several of Mr. Neugeboren's medical providers completely missed his tell-tale signs and symptoms of ischemic heart disease, putting him at great risk of debilitating illness and eventual death by myocardial infarction or stroke. That said, the author also is very determined to clearly acknowledge the additional (and enormous) privilege of having well-educated doctors within his closest circle of friends, all of whom went out of their way to support him, advocate for him, and procure for him the finest surgeons, hospitals, and medical treatment possible within the American healthcare system.

Despite (or perhaps in response to) his own class privilege and elevated societal status as a successful author, Mr. Neugeboren spends a great deal of time discussing what is wrong with American healthcare, eventually coming to the conclusion that access to appropriate, high-quality, affordable, and timely healthcare is the crux of the challenge facing the United States today vis-a-vis the health of its citizens. While he does not offer specific policy solutions to resolve the current healthcare crisis, the author does indeed use citations of appropriate literature to drive home the conclusion that the American healthcare system is broken, the poor are often left out in the cold, and that too many Americans go without healthcare in a country which spends more per capita on healthcare than any other industrialized nation. Taking his findings further, Mr. Neugeboren extrapolates his conclusions further into a global picture, wherein AIDS and other controllable diseases continue to ravage less developed countries, mostly due to a lack of political and economic will on the part of the United States and its economic peers. To wit,

"Valuing freedom of choice over constraints, and individual freedom over government regulation in the specific ways Americans do, we seem a long way from knowing how and when, if ever, we will be able, if in inevitably imperfect ways, to set reasonable and effective national healthcare policies."

The doctor-patient relationship also plays a significant role in Open Heart, and Neugeboren describes how managed care, too much reliance on technology, and the economic pressures which drive the American healthcare system have only served to undermine the trust between patient and doctor. He continues,

"We might begin, if only begin, it occurs to me, by thinking in terms of what my friends and I have been talking about---providing those contexts in which greater access to care, continuity of care, long-term care, preventive measures, and public health measures are encouraged and endowed. If, too, we restore the doctor-patient relationship to a central position in medical care, and if we avail ourselves of the marvelous technologies that exist while at the same time remaining skeptical of those technologies that are more expensive than they are curative (and that cause us to neglect more urgent health-care needs), then, I say, we have a pretty good shot at making it happen."

Neugeboren outlines how American tobacco companies prey on the young and the poor---both here and abroad---to make their profits while undermining the health of the world. He elucidates how access to quality care is often blocked by a class-based system which favors the wealthy and shuttles the poor to understaffed, overburdened, and poorly funded public healthcare facilities. The author also expounds how, in our post-modern awe of expensive technological advances, we have lost sight of what is most important in healthcare---the face-t0-face meeting of doctor and patient. And if that doctor is constrained from spending more than ten minutes with each patient due to increasing malpractice insurance, sky-rocketing overhead, and endless student loan repayments, this is a recipe for misdiagnoses, under-diagnosis, shoddy care, and missed opportunities for preventive measures which can ward off the advent of chronic (and ultimately expensive) disease.

On a global scale, one of the author's closest friends, Jerry Friedland, a medical doctor committed to fighting AIDS in Africa, describes his frustration at the (as of 2002) inadequate response to AIDS in Africa by the industrialized world. Taking a potentially controversial stance, Mr. Friedland and Mr. Neugeboren describe how Americans are quick to respond to sudden catastrophes---like 9/11, where 3,000 people died, however tragically---with fervor and purpose, yet, in the face of a long-term catastrophe like AIDS, we lose our momentum, even in the face of more than 3 million deaths per year in sub-Saharan Africa alone. Of course, they hasten to add, 9/11 was a watershed moment for the world and deserved the attention which it garnered, yet the relative loss and destruction inherent in that singular event cannot compare numerically with the ravages of worldwide disease, antibiotic-resistant organisms, global poverty, famine, ongoing war, and genocide. According to Dr. Richard Horton, the editor of The Lancet, "the major issue in medicine is not one of maintaining the pace of discovery, but of making sure there is equitable access, throughout the world, to the discoveries we have already made."

Citing studies by the World Health Organization, Neugeboren implores the reader to comprehend that, between 1990 and 2020, "unipolar depression (also called clinical depression) is second behind ischemic heart disease, in rank order of the global burden of disease (a measure of health status that quantifies not merely the number of deaths but also the impact of premature death and disability on a population)." He also cites a study stating that, "of the ten leading causes of disability worldwide, five are psychiatric conditions (depression, alcoholism, bipolar disorder, schizophrenia, and obsessive-compulsive disorder)." Food for thought.

Immunization, preventive healthcare, sanitation and hygiene, screening technologies, life-saving medicines---these are all well-understood tools in our arsenal against disease, yet economic constraints, xenophobia, and lack of political will often prevent such simple technologies from reaching those most in need. Lobbyists for the tobacco, alcohol, and firearm industries fill the halls of our Capitol every day, squeezing out the small voices who call for parity, justice, and equal access to quality healthcare for all. It is a sad state of affairs, and authors like Jay Neugeboren are able to bring such disparities to bear with wit, wisdom, and personal reflection.

Open Heart not only explores the challenges of personal, national, and global healthcare in the 21st century. It is also an ode to friendship, to connection, to self-reflection, and to gratitude for life. From the micro to the macro, from the familiar to the foreign, we are urged to consider the whole, be it our best friend down the street or an AIDS orphan in Niger. There is no qualitative difference between your visit to your local doctor and that orphan's need for a 20-cent immunization against measles. But there is a quantitative difference, and that orphan, sadly, is much more likely to be denied what she needs to survive.

We have a choice, and Mr. Neugeboren has given us a gift to once again see that choice clearly. I, for one, accept that gift gratefully, and will continue to bear in mind the lack of such a qualitative difference between me and that orphan, and will use my voice to remind others of her equal right to life, liberty, health and the pursuit of happiness.

Monday, November 12, 2007

Leave of Absence and Its (Dis)Contents

Being on a leave of absence presents a series of challenges, most of which I would deem "problems of luxury", yet their problematic quality is still worthy of my attention. And it is these challenges which occupy my mind most vividly from day to day.

First and foremost, during this time of rejuvenation and mental/emotional recovery, I am faced with the question of whether or not to return to my full-time job. Being on a medical leave of absence, I am required by law to return to work for at least 30 calendar days following my leave, yet the future beyond those thirty days is wholly uncertain, professionally speaking. My job---and all of its vicissitudes and benefits---is doubtless waiting for me to return in just under a month, and my desire to embrace that 40-hour challenge once again is waning daily.

So, the questions remain. What would it mean to leave my workplace, my work family, the comfort of the familiar? How would it impact my career, my personal life, my clinical development, my future as a nurse? How much should I worry about my patients and how my leave-taking will effect them? How much of my patients' experience is my responsibility? Haven't I given them enough for seven long years?

If I do indeed decide to leave my position, it begs the question of how I will move forward, earn a living, and piece together a sane, healthy work life, unencumbered by the burnout with which I have lived for far too long. Luckily, Mary is poised to have benefits early in 2008, ostensibly freeing me from the oh-so-American shackles of sticking with a job solely for the health insurance.

This opening which I have created for myself is truly an opening---a portal of opportunity---through which I can walk, run, saunter, stumble, or fall. The mode of entry through said portal still remains to be seen, but the desired outcome is, in the final analysis, sanity.

Saturday, November 10, 2007

Compassion on My Mother's Birthday

I received the following email today, my mother's 75th birthday, her first birthday as a widow......

Evoking the power of compassion in us is not always easy. I find myself that the simplest ways are the best and the most direct. Every day, life gives us innumerable chances to open our hearts, if we can only take them. An old woman passes you with a sad and lonely face and two heavy plastic bags full of shopping she can hardly carry. Switch on a television, and there on the news is a mother in Beirut kneeling above the body of her murdered son, or an old grandmother in Moscow pointing to the thin soup that is her only food. . . .

Any one of these sights could open the eyes of your heart to the fact of vast suffering in the world. Let it. Don’t waste the love and grief it arouses. In the moment you feel compassion welling up in you, don’t brush it aside, don’t shrug it off and try quickly to return to “normal,” don’t be afraid of your feeling or be embarrassed by it, and don’t allow yourself to be distracted from it. Be vulnerable: Use that quick, bright uprush of compassion—focus on it, go deep into your heart and meditate on it, develop it, enhance and deepen it. By doing this you will realize how blind you have been to suffering.

All beings, everywhere, suffer; let your heart go out to them all in spontaneous and immeasurable compassion.

---Sogyal Rinpoche

Friday, November 09, 2007

Darfur Now

Last night, I had the opportunity to see an advance screening of Darfur Now, a new documentary about the crisis in the Darfur region of Sudan. MTV apparently released advanced copies of the film to student activist groups across the country, and I was able to see the film at our local university under the auspices of our local chapter of STAND.

The film, which is already receiving mixed reviews, follows the struggles of six individuals, including Don Cheadle (of Hotel Rwanda fame); Luis Moreno-Ocampo, principle prosecutor for the International Criminal Court in The Hague; Pablo Recalde, a UN employee in charge of aid distribution by the U.N.'s World Food Program within Darfur; Hejewa Adam, a Darfurian woman who has joined a rebel group after her baby was murdered by the Janjaweed militia; Adam Sterling, a California-based activist; and Ahmed Mohammed Abakar, a Sheik living in a refugee camp and helping to organizing and support the thousands encamped there.

Fast-paced and informative in a general way, the film gives the viewer a relatively surface-level review of the conflict, the genocide, some of the major players, and the geopolitics therein. Many reviews take the film to task for various shortcomings---many criticisms with which I agree---yet I can honestly say that the overall take-away message is one of cautious optimism. The film is obviously meant to leave the viewer feeling uplifted by the successful activism witnessed on the screen, while still allowing that the reality of thousands dead and thousands more displaced is nowhere near resolved. Still, the viewer gets to see Mr. Sterling, flanked by Don Cheadle and George Clooney, celebrate as Arnold Schwarzenegger signs a law enacting California's divestment from any businesses connected with the Sudanese government. The viewer also sees an uplifting montage of Mr. Cheadle's many public speaking engagements and book tour with co-author John Prendergast, with laughter and heartfelt sentiments peppered throughout.

Poignant moments include a band of female rebels, armed with semi-automatic weapons, waiting in the jungle to strike an unsuspecting enemy who roam the region on sprees of destruction. While they wait, the women discuss the U.N., the need for a multinational peace-keeping force, and wonder aloud when "the white people" will arrive to help them. One woman repeats the name of the International Criminal Court's main prosecutor, as if his name were a prayer just waiting to be answered. Meanwhile, the wheels of justice in The Hague turn painfully slowly, and indicted Sudanese war criminals act with impunity, their government refusing to extradite them for trial. The women's words echo in the jungle landscape, the irony of their current isolation painful to witness.

My niece, a well-known college-age Darfur activist, says that Darfur Now is a "activist burnout prevention film" which she and her hard-working colleagues watch periodically for a shot in the arm and a moral/emotional boost. If the daring viewer/activist would like a more realistic and less optimistic view of the Darfur conflict and genocide, The Devil Came on Horseback comes highly recommended. As my niece warned me, Darfur Now leaves you feeling like you can personally make a difference, while The Devil Came on Horseback may leave one utterly demoralized and depressed. With complicated and tragic situations like Darfur, it's apparent that we need both influences on the citizenry's table. One film may knock you to the ground with its stark realism, while the other lifts you back on your feet again with more gentle threads of hope. See them both, and then take action.