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Sporadic photos and notes from a Psyche-midwife, cheerleader, anthropologist--aka clinical social worker in therapy practice. Photos are usually mine except for those of historical events/famous people. Music relevant to the daily topic is often included in a web video embedded below the blog. Click on highlighted links in the copy to get to source or supplemental material. For contact information, see my website @ janasvoboda.com or click on the button to the right below. Join in the conversation.

Monday, February 23, 2015

Mental Health is a Physical Heath Issue

CAN I see another’s woe,
And not be in sorrow too?
Can I see another’s grief,
And not seek for kind relief?
      ~~ William Blake
Songs of Innocence and Experience

I recently took a sabbatical from my private practice counseling to start work with a grant program.  Its intention is to explore integration of mental health services into family practice medicine.  What a great idea.

Studies show around 80% of people with anxiety and depression never see anyone about these issues except their PCPs (primary care medical folks).  Many persistent and "medically unexplained" physical symptoms are the result of trauma, stress and untreated depression and anxiety. Since most people see their PCP at least once a year, it makes a lot of sense to have a mental health professional at the ready and in their medical home.  My grant takes me to a clinic that serves over 10,000 adults and children.  Over half of them are on the Oregon health plan, meaning they live at or below the poverty line.

Most insurances now, including public health, are required by law to offer coverage for "mental" illnesses.  I have never understood the notion that the emotional and mental processes are somehow supposed to happen separately of the body.  All are contained within the same vehicle, right?  And by now, surely, most of us understand that what we translate as emotion and even thought has a physical corollary.

Short digression:  truth is that the previous statement is not true.  Not everybody gets this connection.
So imagine this:  You are readying to cross the street just as the "Don't Walk" light changes to "Walk".  Entering the crosswalk, an inattentive driver turning right enters, missing you by a few feet.  Inattentive driver speeds on, maybe not even having noticed you.  But you noticed, as did your body.  You've just had a brush with death.  In an instant, you've gone from calm to agitated.  Your heart races, your blood pressure skyrockets, your breathing increases.  Less noticeably, your pupils enlarge, the tiny blood vessels in your hands and feet contract.  Your hair may even be standing on end. You logically know you are safe-- the car is gone, and you are intact.  But it will be at least several minutes before your body catches up with your mind.

What's happened?
On sensing an imminent danger, your body releases a chemical cascade designed to help you survive the threat.  This cocktail contains numerous substances, the most commonly known being adrenaline.  The chemicals have many effects intended to increase your chances of living.  Your pupils enlarge to help you take in the visual field and see chances for escape or weapons for use.  Your hair is standing on end because of an evolutionary quirk that works for many mammals, though not so much for humans: to make you look bigger.  Think raccoon or freaked out cat.  Your increased heart rate, blood pressure and breathing is sending oxygen to your large muscles (thighs and biceps) to help you run and fight.  Your cold hands and feet are diverting the blood to the more important internal organs.  Even the capillaries on the surface of your skin are contracting, so you won't bleed to death as quickly.

In short, your body is doing what it needs to.  And your brain is interpreting all this as FEAR, and filing it away under THINGS TO AVOID.

But fear, in this case, is just your body's shorthand to describe that chemical cascade and its connection to threat.

OK, that was a long diversion.  Let's assume that between your previous knowledge or this new information, you  understand that what happens to the "mind" is also/really happening to the body.    One affects the other.  The software (thinking) affects the hardware (body).  Addressing only physical symptoms without addressing the underlying stresses that bring them, continue them or worsen them doesn't make sense in the long run.  Our state seems to agree with that, which is why I am now doing therapy work within the context of a Medical Home model.

But not everyone gets this.  There is still a lot of  stigma about emotional health issues, and misunderstanding about stress-related illnesses.  And there are still many people who would be completely offended to be referred to a mental health professional.

Many people think that when a doctor/PCP tells them their symptoms are stress related, they are being told they are making them up, or faking them, or can fix them by just relaxing a little.  I didn't quite understand this myself, until I heard a great interview with an immunologist on Krista Tippet's public radio show.  At the time the show was called "Speaking of Faith".  To not scare the unchurched, it's now called "On Being".  The doctor, Esther Sternberg, explained in very clear terms the effects of stress on the physical body and the life-endangering damage it can do.  Click the link to hear the whole show.  The short story:  trauma and stress can damage the immune system and worsen or cause real disease. These symptoms are not in your head, they are happening to and in your body.

In the last two months or so, I have been able to see people who would NEVER have come to my private practice office.  But when their doctors (thank you for trusting me, docs!) tell them, hey, we have someone here who knows a lot about X (helping you with your racing heart/worrisome thoughts/grief over your loss/high blood pressure) and let me come in and say hi during a visit, they welcome the opportunity to tell their story, be witnessed and heard.  They appreciate being offered practical tools for calming their physiology, and being told that a normal human reaction to suffering is not pathology.

Many of the people I have seen the last two months have had a great deal of trauma in their lives.  Trauma has a marked effect on the body, and kindles the brain in a way that can cause ongoing difficulty in regulating emotions and handling stress.  Many have never discussed this trauma with another person before, because of shame or because it happened long ago and they thought they were supposed to be over it as adults.  They had developing defenses and coping mechanisms that served for a while and then stopped working or had too many side effects (self-medicating through substances or other numbing mechanisms, self isolating, anger).

These are also people who, even if they WANTED to see a therapist, might not have been able to do so.  Most private practices in my town are full.  My own practice gets 5-10 inquiries a week. Most only accept a few insurances, either because the panels are closed for new providers (I DO NOT GET THIS!  THERE IS SUCH DEMAND!) or because they choose not to participate due to the bureaucracy involved and low reimbursement.  Even the so-called public services turn away clients regularly and create numerous barriers to care:  lengthy waiting periods, intimidatingly personal paperwork requested without creating trust, mandated length-of-service before even knowing what the problems are, and lack of any assurance of privacy.

I get the problems.  Money doesn't grow on trees, and demands exceed supplies.  But we are being very short-sighted if we think we are saving money by refusing people support in managing the incredible stress of being human, and then spend billions to treat the illnesses this stress causes.

I am so very grateful to the doctors of Samaritan Family Medicine Residents Clinic who have trusted
me to assist their patients.  It took a little convincing.  And I am not great at measuring the data to show it is making a difference. Obviously I can't share with you the details of specific patients for whom this is working. But I can tell you that people coming in with heart pains are learning to take time to appreciate what is good in the world and to soothe their worried souls, and people who have been afraid to connect with others are making friends, and people who were ashamed that they were sad and needed space to grieve are back at work.  I am grateful to them for sharing their stories, their pain and their trust with me.

A few years ago, I took advantage of my generous insurance program to visit a specialist in hopes of finding relief from my persistent allergic reaction to Everything Oregon.  20 minutes and $890 (insurance) dollars later, it was confirmed by Science that I'm indeed allergic to most major crops and native plants of Oregon.  I was advised I would likely remain so, but could take the same over-the-counter stuff that seems to make me cranky and depressed if I wanted to sniffle less.  At current insurance reimbursement rates for my services, I could have seen someone with anxiety and depression a dozen times and offered them some tools and support that may have lessened the chances of a $2000 ER visit, lost work time, a relationship crisis, etc.  Something is wrong here.

I see the value in what I can do.  I hope the future of medicine sees the same.  That feels unlikely, as long as mental health is seen as moral/willpower issue instead of a medical one.  I'm going to talk with my representative, Sara Acres Gesler, to see what we can do about that.  I hope that you will do what you can to promote increasing access to emotional and mental health services in the country.


Monday, February 9, 2015

Paul Bogard on Knowing the Night

I met author Paul Bogard when he came to our little town to read from his book, The End of Night.  Accompanied by brilliant pictures of the night sky, and heartbreaking statistics about the effects of human-caused light pollution on biological diversity, human sleep and mental health, he spoke to a deep wise place in many of us who know we need that dark, bad.  One stat from his book:  current estimates are that fewer than 2/3s of the human population can now see the Milky Way, a staple of my Kansas childhood evenings.    Our urban skies are deficient in visible planets, the stars there are paltry.  What books, music, philosophies are lost because the jeweled sky is but a hazy blur to this generation? Does the constant intrusion of lights into our bedroom doom us to fragmented, restorative sleep and thus explain our cranky, achy, carb-seeking haze with which we stumble thought our lives? I highly recommend his read, and then take it a step further and investigate the beauty of the dark places.  In the day time, advocate for light reduction at home and on the streets, and give us back our beautiful diamond blanket.   You can read more of his work at his website: http://www.paul-bogard.com
Paul is a walker, a writer, and a passionate lover of the skies.  His latest book was lauded by many:"A lyrical, far-reaching book. Part elegy, part call-to-arms, The End of Night feels like an essential addition to the literature of nature." —Boston Globe.   A native Minnesotan, Paul grew up watching the stars and moon from a lake in the northern part of the state. He has lived and taught in New Mexico, Nevada, Wisconsin, and North Carolina, and is now assistant professor of English at James Madison University in Harrisonburg, Virginia, where he teaches creative nonfiction and environmental literature. He's been featured on NPR and Slate.   and is currently working on a new book called Touching the Ground.    Pics by me, a fellow Lunatic.---jls

WALKING AT NIGHT UNDER A WAXING GIBBOUS                                                                                         Paul Bogard

When my dog Luna was alive we would walk nearly every night before midnight. Luna was under voice control and hardly knew a leash during her 15-year life. We probably went for a thousand walks a year together, including one the night before she left this life. We would walk first thing in the morning, in the evening after work, and then, before bed, this walk before midnight. I loved walking with her anytime, but I especially loved these walks at night. 
I have always loved the way the world comes down in speed and size at night. Less noise, fewer cars, fewer people. I can feel myself exhale at night, as though I've been holding my breath all day, dealing with the stress of daily life. I have to believe it's been this way for countless people over
the ages--night and its beautiful darkness give us the chance to exhale, to breathe out the day's worry and breathe in the night's calm. Before Luna came along, I had seldom walked at night, before midnight, getting out into the neighborhood.  Sometimes, but not regularly, not as a practice, a regular returning ritual, a set part of every day.
She would race across lawns, from house to house--even back behind the houses, finding who knows what, her birddog senses fully alive--then return to check in, make sure I was coming along. And I was, slowly, sauntering--these walks weren't about getting anywhere, or exercise. I'd just stroll along, down the sidewalk, down to the park, around the block. We seldom ran into other people. That's one thing you notice when you get out at night,
"To know the dark, go dark." Wendell Berry
how few of us are outside savoring this time. How we close our doors and shutter our windows, enclose ourselves in our boxes, watching our boxes. From windows in house after house, in whatever neighborhood we walked--Albuquerque, Reno, Ashland, Winston-Salem, Harrisonburg--glowed television's blue. Mostly, I loved this. I didn't want to see anyone. I loved having the night to myself, with my beautiful dog racing joyfully, twirling fallen leaves like a gust of wind as she crossed lawn after lawn.
But there was always a small twist of sadness, just seeing how few people were out. We know so little about night, about darkness--we ignore it, avoid it, fear it. And yet, it's so important to our lives. There were often nights so beautiful--a moon, a soft rain, huge snowflakes floating down--that I could not believe Luna and I were the only ones out.
Last night, all my shades were drawn. I watched a three-hour hockey game (my Minnesota Gophers), the blue glow of my television seeping out into the night. I was so cut off from the night outside--there could have been a herd of buffalo encircling my house, or... anything, really, and I would have had no idea. It was a night like most nights now--Luna gone eight months--where I lower my shades at dusk and don't go back outside. I suppose it's because I knew there were no buffalo encircling my house--or anything, really, out of the ordinary. It was just night. And with no Luna to get me out, I stay inside.
Except that last night I walked in my neighborhood before midnight. I changed
into jeans, put on my hoody, laced my old running shoes--just as I used to when Luna used to come stand next to me wherever I was when it was time to walk--and just wait for me to take her out. Maybe it's because the Gophers had been beaten by a better team and I felt a little down. But maybe it's because I remembered that a waxing gibbous would be high overhead.
And it was, that wonderful old moon, as it always has been. Around the block I strolled, remembering, soaking up the beautiful night. Breathing again, feeling connected--to my past, to the me I love, to this wonderful world. Luna with me, every step of the way.

Click here to find audio interviews on Dark Skies Initiatives, and why they matter.

"To know the dark, go dark." --Wendell Berry

Now in paperback from Little, Brown/Back Bay Books: The End of Night: Searching for Natural Darkness in an Age of Artificial Light
Please visit www.paul-bogard.com to find out more.

Friday, February 6, 2015

On Letting Go: poet Mari L'Esperance

A thoughtful essay on paying attention when psyche comes knocking, by poet Mari L'Esperance. From her bio: Born in Kobe, Japan to a Japanese mother and a French Canadian-New Englander father, Mari is the author of The Darkened Temple (awarded a Prairie Schooner Book Prize in Poetry and published in September 2008 by the University of Nebraska Press) and an earlier collection Begin Here (awarded a Sarasota Poetry Theatre Press Chapbook Prize). Coming Close: Forty Essays on Philip Levine, co-edited with Tomás Q. Morín, was published by Prairie Lights Books in May 2013. The recipient of awards from the New York Times, New York University, Djerassi, Hedgebrook, and Dorland Mountain Arts Colony, L’Esperance lives and works in the Los Angeles area. You can read more about her at her website, http://www.marilesperance.com/
Letting Go     1/31/15 

A stranger once said to me, “Life has many chapters.” I’ve carried her words with me ever since. In the new year I’ve been giving much thought to the notion—and conscious choice, or, more often, a series of choices—of letting go and have been experiencing internal movement and a rekindled sense of possibility the more I allow myself to reflect upon it.

Letting go of what no longer serves us—aspects of the past, draining or one-sided relationships, a distorted self-image, joyless work—becomes even more urgent in midlife, that snarled thicket in which I now find myself (cue Dante). The no-longer-deniable reality of my mortality, of narrowing options—all part of aging, awakening, and deepening—have forced me to confront myself in ways I find simultaneously uncomfortable, scary, and enlivening. Let’s just say the universe has turned the volume way up and I’m finally beginning to listen and pay attention rather than defend against it in a host of ways.

It’s been my experience that we invite in and nurture growth and vitality when we attend to, and follow, what energizes and excites us. When we’re shackled (sometimes unconsciously, sometimes not) to a sense of obligation or duty to others—family, society, a profession, a way of being—it can be easy to lose contact with what holds meaning on a personal level, with what feeds the soul. We can also find ourselves “shackled” as the result of uninvited life circumstances: it’s well known that trauma can freeze us in a caul of fear and risk aversion so that any reaching for the new feels potentially annihilating, even though that reaching is life affirming and necessary to our development. All that said, I’m also aware that, for me, letting go is about finding a balance between “obligation” and “freedom”—that one can’t exist without the other.

One of the areas in which I’ve been sensing this growing urgency to let go is in my writing. For as long as I’ve been writing poems (over 20 years, and with uneven consistency) I’ve identified as a poet, first and foremost. But in the past few months I’ve become increasingly aware of a quiet yearning to write something bigger—something in (gasp!) prose. Just the thought feels terrifying and overwhelming—yes, potentially annihilating. After all, it’s the unknown! Disaster and Failure lurk around every corner! And what about Poetry, my first love and constant companion these many, sometimes-hard years? Poems—those lifeboats of meaning, feeling, image, sense, and sound—held me in, held me up on a dark and roiling sea. Setting poems aside, even temporarily, to commit to a prose work feels like an act of betrayal. And yet I’m finding it increasingly difficult to ignore prose’s pull. So I’m trying (trying) to stay open to what arises, and follow it, rather than adhere irrationally to self-limiting “shoulds”. Maybe there’s a way that what comes in the writing doesn’t have to be one or the other—that integration is possible. Poetry and prose living together on the page. Time will tell.

My friend Leslie McGrath, a poet and writer with formal training in clinical psychology, once counseled me

to let go of what I’ve long thought I should be doing, in my life and creative work, so that I can finally be released to do what I’m intended to do—whatever that might be. American psychologist Abraham Maslow said, “You will either step forward into growth or you will step back into safety.” Stepping fully into life’s flow, with openness and receptivity to all that it offers, is both frightening and exhilarating. So I’m paying attention to those small internal voices and grooming my feathers.
                                                --Mari L'Esperance, Winter 2015

Read more:  Review of  The Book of Scented Things, Chicago Times
Review of The Darkened Temple, in Rattle poetry journal