Lewis Mehl-Madrona

Contemporary Psychotherapy

2009-05-28T19:06:00.004-07:00

I wanted to share some comments from Healing Plots, a book by Amia Lieblich, et al, with which I very much resonate. They write that psychotherapy and counseling are unique and distinctive modern cultural inventions which resonates true to me. These forms could have never existed before in history and may never exist again. At least, I hope/think that we are evolving away from these structures toward a more indigenous healing template. Lieblich, et al write that therapy arose to fill the gaps left behind as traditional forms of problem solving and meaning-making dissolved. "Therapy provided meaning bridges between the compartments of increasingly fragmented modern lives." What John McLeod, in the first chapter in this anthology, writes, that means so much to me, is his description of how the key values of psychotherapy match the key values of rational modernity. Psychotherapy of the 20th century was all about rationality and a detached approach to the world. It was about controlling the expression of feeling. People who feel too much are labeled as are people who feel different from the established norm. These people gain diagnosis and are the subject of a system of "care" which purports to channel their expression of emotion into acceptable forms by any means possible, even electroconvulsive thrapies, or previously, lobotomies. The goal of 20th century psychotherapy was control. It is based upon the idea of continual self-improvement through the progression of science, which, in my estimation, has not apparently been borne out. McLeod writes about the explosion of possibilities of identity construction inherent in a capitalistic system of consumption in which we attempt to construct or purchase an identity of our choice based upon the stories rampant within the culture about what is desirable.

Neurobiology Learning Society of Honolulu: learning, mirror neurons, and dreams.

2009-04-06T07:35:00.001-07:00

In April, the Neurobiology Learning Society met in Honolulu at 1601 Kapiolani Ave (Intercultural Communication College offices). Argosy University student Janalle Kaloi-Chen (see http://groups.google.com/group/argosypsychopharmacology) summarized the meeting. I reproduce parts of her summary and add my comments about the meeting, which I attended as well. (The group meets on the first Wednesday of every month at the above location).

The first speaker (Joli Malone) presented on Stress and Learning. She
spoke about the structures of the limbic system that are involved in
learning including the thalamus, hypothalamus, amygdala, and
hippocampus. The hippocampus helps to encode important information
from short-term memory into long-term memory. The hippocampus is
connected to the amygdale in such a way that hypervigilence leaves little energy or
attention for learning. In keeping with Dan Janik's writing, it appears that the fear-based learning environments that are all too common in North American and Hawai'ian education from grade 1 through graduate school actually interferes with learning. Perception of the learning event affects what gets remembered and
with how much detail. Threat triggers a survival instinct and may
prevent or hinder learning. Joli spoke about the kinds of stress that
a student has including: bullying, negative-evaluations from the
teacher, poor peer interactions, lack of support or nurturing
environment, fear for personal safety, not speaking the dominant
school language, and prejudice or discrimination. She concluded by
going over various ways we can decrease stress of our students
including: providing a safe school environment and providing supports
to children and families. And finally, having children exercise, play
music, and engage in positive social interactions increase endorphin
levels which tend to off-set the negative effects of cortisol.

The second speaker (Marissa Moon) spoke about how the Mirror Neurons
Systems help us diagnose autism. She explained that it mirror neurons allow us to
directly match actions of others and to generate explanations for their behavior based on what our motivations would be if we were engaging in those same behaviors. They were discovered in the brains of adult
primates. The quote she used to describe them was, "When the
observation of an action performed by another individual evokes a
neural activity that corresponds to that which, when internally
generated, represents a certain action, the meaning of it should be
recognized, because of the similarity between two representations.
Mirror Neurons (MNS) appear to be important to many areas of human
development such as language acquisition, imitation of actions,
empathy, and theory of mind. Thus impairments in the MNS may play a
role in psychopathologies, especially those with Autism spectrum
disorders, who appear to lack empathy.

The last speaker, Leslie Kunimura spoke about dreams and
schizophrenia. The ability to generate rational thoughts is greatly
weakened in dreaming. She spoke about the similarities between schizophrenia and
normal dreaming since both involve hallucinations, delusions,
cognitive abnormalities, heightened emotionality and a loss of
reality. Her topic seemed to resound with many of us who have worked
with individuals with schizophrenia.

These were great topics for discussion because they allow us to see how our social relationships, social context, and social environment affect our brains. It gave me pause for thought. I notice that some students at Argosy, where I teach, are more comfortable with the fear-based learning system in which the teacher passes out information, the students learn it, and regurgitate it back on exams for a grade. My wish is for us to be less fear based – for us to, in essence, contract for grades in a system in which the students sees what the work needs to be for obtaining a particular grade and has the opportunity to get the grade he or she desires. Of course, this means that we become less "regurgitating information" based and more "process based" in which we learn how to learn about the particular subject matter and not necessarily learn all the same facts, but do all learn where to find those facts and what the controversies are in the field, and where the cutting edges might lie. I'm going to modify my approach next term, to have more small, frequently rewarded, creative learning tasks instead of asking students to pace themselves to turn in material (since they always turn it in at the end and then can't work together with me to boost their grade to what they want).

Regarding the last discussion, Argosy student Laura Epstein, posted a quote on our class discussion from Oliver Sacks that I want to share. In "The Last Hippie", he described someone who was stuck in the 60's due to a large tumor that had been removed, causing considerable brain. He then wrote,"Dreaming and waking, for us, are usually distinct-dreaming is enclosed in sleep and enjoys a special license because it is cut off from external perception and action; while waking perception is constrained by reality. But in Greg the boundary between waking and sleep seemed to break down, and what emerged was a sort of waking or public dream, in which dreamlike fancies and associations and symbols would proliferate and weave themselves into the waking perceptions of the mind. These associations were often startling and sometimes surrealistic in quality. They showed the power of fancy at play and, specifically, the … characteristic of dreams."

A number of us at the meeting remarked at how our schizophrenic patients seemed to be living within a dream, and I speculated that schizophrenia (or whatever it is) would have to be some exaggeration or inappropriate expression of something we all already do rather than a qualitatively different brain phenomenon. I think living partially or fully within a dream sums up many of our experiences with schizophrenia-like symptoms. Also, it helps us to explain the lack of narrative coherence and ability often found among the schizophrenically diagnosed – they cannot tell stories about their experience because, to tell a story, one has to step out of the experience and reflect upon it and edit it and restructure and shape it. If one is lost in the experience that won't happen.

Lewis

Drug Vs. Social Factors Binary Thinking

2009-04-06T06:59:00.001-07:00

An article on drug development for anorexia caught my attention. See it at:

http://www.telegraph.co.uk/health/healthnews/5068308/Anorexia-drugs-o...

Here's the short version:

"Drugs to treat anorexia could be developed following research which
found physical changes to the brain in the womb may be partly
responsible for the condition.

"Researchers found that 70 per cent of anorexic children and young
people they studied showed signs of problems with neurotransmitters,
chemicals which help brain cells communicate.

"Their report, to be unveiled at a conference at the Institute of
Education in London this week, suggests that these developmental
changes meant the patients were particularly vulnerable to eating
disorders, prompting its authors to propose screening children at the
age of eight and experts to claim it could "pave the way for the first
drugs".

"'Arguments that social factors such as girls feeling under pressure to
lose weight in order to look like high-profile women in the media
contain logical flaws because almost everyone is exposed to them, yet
only a small percentage of young people get anorexia.'

"Susan Ringwood, chief executive of Beat, an eating disorder charity,
said the research could 'pave the way for the first drugs to be
developed to treat eating disorders, similar to the way that anti-
depressants help rebalance the brain of people with depression'.

"'Parents always blame themselves,' she said, 'but what we are learning
more and more is that some people are very vulnerable to anorexia and
that is down to genetic factors and brain chemistry and not them
trying to look like celebrity models or suffering a major traumatic
even early in their lives.'

This piece clearly illustrates the social construction of "mental disorders." First, ignore the question as to whether or not eating disorders or depression exist or not. That's the topic of another blog.

Look at this paragraph:

"Parents always blame themselves," she said, "but what we are learning more and more is that some people are very vulnerable to anorexia and that is down to genetic factors and brain chemistry and not them trying to look like celebrity models or suffering a major traumatic even early in their lives."

The implicit message is that "mental disorders" (specifically eating disorders, depression) are caused by "genetic factors and brain chemistry" and that these changes "happen in the womb."

The authors imply, if something is caused by "genetic factors and brain chemistry", then it cannot be caused by social factors or family factors ("not trying to look like celebrity models or suffering a major traumatic event early in their lives." Of course, the other implication is that there is one cause and that the most proximate cause is brain changes that occur during fetal development.

The other implications is that psychological causes are equated to trauma and that parents are responsible for any trauma that children experience and will blame themselves (should, could, would) if suffering is due to trauma experienced.

What an interesting world view -- that we are robots to genetics and brain chemistry and that this is somehow preferable.

Do you see the binary thinking? Also, I wonder why parents would torture themselves about brain changes that happen in the womb.

In my view, of course, social relationships and social constructions (collective representations as well) create brains and modify genetics (epigenetics) and this type of binary thinking is simplistically dangerous in the sense that modifying brain chemistry without modifying social networks and relationships may short-term reduce symptoms but is long-term doomed to failure.

Thoughts?

Lewis

2009-03-23T06:39:00.003-07:00

I'm recommending Judith Orloff's new book to my friends and colleagues. It's called Emotional Freedom.

For more information, see Judith's website for the book.

I wish I could do what Judith has done. She has distilled insights from the world's philosophies and psychologies into simple insights and stories that anyone can follow. This is a really valuable self-help book for lots of people in these times of fear and dread, because the techniques, used as she instructs and illustrates, have worked for people for centuries and are so necessary in today's frenetic times.

Way to go, Judith, for writing another really great book.

Lewis

Psychiatry and Aboriginal North America

2009-03-23T06:32:00.000-07:00

Native American culture and psychiatry

Native American people are typically diagnosed with higher rates of “mental illness” than white North Americans. Similar findings occur in Australia and New Zealand. Historically Native American people were viewed by psychiatry as primitive, narcissistic, and withdrawn, among a host of pejorative attributes. Early psychoanalytic research leaned heavily on Native Americans to demonstrate primitive defense mechanisms and the inherent deficiencies of being on the margin of civilization. Gustafson (1976), for example, wrote that Lakota people were to primitive to engage in psychoanalysis, being unable to consider that lying on a couch and talking to someone who doesn’t answer might seem ridiculous to members of another culture who had not learned to value this procedure.
Higher rates of depression, anxiety, and other illnesses have been documented among North America’s aboriginal people. However, when Mansur and colleagues (2007), for example, looked at the rates of anxiety and depression on reservations in Montana, they were actually lower than the white communities around the reservation. They explained their findings by the much greater social support and family connectedness existing on reservations than in white communities. Therese O’Nell (2000) went to a Flathead community in Montana, expecting to find high rates of depression. Instead she found a cultural and linguistic mismapping of what Flathead people consider to be a highly desirable state (“to be worthy of pity”) onto what mainstream psychiatry calls “depression.” Flatheads who were worthy of pity did not appear to be depressed in the DSM sense of the word, at least to her.
Native Americans are also accused of having more alcoholism than white Americans, though research shows actual lower levels of alcoholism and higher levels of binge drinking on reserves than their neighboring white communities. Nevertheless, the stereotype of the drunken Indian has become a cultural icon, for both aboriginal and non-aboriginal people. O’Nell describes drinking and being drunk as being a potential source of Indian pride and ethnic identification among Flathead people in Montana. Thacker (2006) describes the historical origins of binge drinking in laws that put an Indian in jail for one day for being drunk and for 90 days for being in possession of alcohol. The law conspired to produce a motto of “when you drink, drink it all”. Dry reserves and still existent laws limit opportunities to learn and practice more responsible, low level consumption of alcohol. Psychiatry has attempted to paint a picture of aboriginal people being genetically susceptible to alcoholism, when poverty actually serves as a sufficient explanation. Social determinants of emotional pain and suffering are readily appreciated on aboriginal reserves (high unemployment, crowded housing, poverty, little social enrichment or recreational opportunities), though psychiatry searches for genetic, deterministic explanations for higher rates of suffering and pain. Given the stewardship of the mental health profession by psychiatrists, resources are directed toward increased access to biomedical care, hospitalizations, 28 day treatment programs, and medications, than to solving the social problems which contribute toward substance abuse on reserves. Certainly, during my four years of working on reserves in rural and remote Saskatchewan, I encountered unlimited funds to send people by themselves to 28 day substance abuse treatment programs and no funds to develop community resources for when they came home. Apparently alcohol policies were managed by competing departments. Health Canada would pay for an unlimited succession of 28 day hospitalizations, but very little in the way of community development and social resources for maintaining a healthy lifestyle.
Historical reports by early explorers and missionaries of North American peoples call forth images of happy, sociable, gregarious people. While we do not want to overly romanticize pre-contact culture, we can say that generosity and hospitality were seen as virtues (see Potlatch cultures). Suicide, except in situations of grave dishonor, was rare. Children were raised in a manner that promoted healthy attachments, as is common in tribal cultures. War, of course, existed, but not on the scale of European battles. Food was relatively plentiful unlike the famines of Europe. Some degree of interpersonal conflict existed, but police are relatively unnecessary in extended kinship systems because relatives keep their relatives in line. Indeed, beliefs about reincarnation and not being able to escape from one’s difficulties through death probably contributed to people working out difficulties in the present, as well as keeping the suicide rate low. Additionally, practices in which the family was responsible for the deeds of its members mitigated against bad deeds lest all in the family suffer. For example, in some communities, if one family member murdered a member of another family, that family had the right to pick a member of the murderer’s family to kill, to maintain balance. In this case, perhaps the threat of retribution was prohibitory. Additionally, the absence of alcoholic beverages over 5 or 6% alcohol probably helped, since current violent deeds are more often than not associated with intoxication. The lack of other substances of abuse and the cultural taboos of using substances outside of ceremony were also contributory to the social fabric remaining intact. The cultural emphasis on healing, balance, and harmony, and the dramatic opportunities for enactment of illness in ceremonies and rituals contributed to keeping the people psychologically healthy. Additionally, the lifestyle of hunter-gathering people was indeed much less stressful than the agricultural lives of peasants in Europe. Some anthropologists have calculated a 16 hour work-week for aboriginal people in North America, with the remainder of their time spent in ceremonial pursuits or social relationships. The social standard of life, including participatory democracy, enlightened childrearing practices, and awareness of the public health importance of hygiene, were much further advanced in the Americas in 1492 than in Europe, with the exception of the empires of Meso-America and South America, in which forced servitude and mass executions on a scale comparable to England of the same time, existed. Life under the Aztec, Incan, or Mayan emperors was not necessarily much better than life in feudal France, England, or Spain. Nevertheless, North Americans enjoyed a reasonably good standard of life, superior in my view to conditions existing in Europe at the same time.
Historical aboriginal views of mind and mental health were quite different from those of contemporary psychiatry (Mehl-Madrona & Pennycook, 2009). These views are being pieced together through interviews with contemporary elders and through written materials collected by ethnologists, physicians (notably Walker and Eastman for the Oglala), missionaries (Father Beuchtel for the Lakota) and explorers. These views as currently reconstructed were more similar to those of the Russian psychologist, Mikhail Bakhtin, and are compatible with much of what is now being called narrative psychology, which, not surprisingly, is the only branch of psychology to have arisen from ethnic and Native studies, women’s studies, and cross-cultural literary disciplines. Aboriginal views held people as fundamentally healthy and whole. Difficulties emerged from learning and living the wrong stories (for the situation at hand). Self was viewed as relational in the sense of multiple selves existing, one for each relationship in which the person found him or herself. No one self was true or primary. Each self had its own voice, which was mingled with the voices of nature, ancestors, spirits, and the like, to produce a veritable symphony of the mind. The community was considered the basic unit of distress when problems emerged and the individuals expressing distress were likened to our now famous metaphor of canaries in the mine. These people were thanked for suffering for the community and bringing into the open the need for the community to heal. Contemporary Dene ceremonies in northern Arizona continue to display this philosophy in which the entire community feels responsible for the sickness of the individual and all contribute to the enactment of a 9 to 14 day ceremony to restore harmony, balance, and health to the individual and simultaneously to the community.
Contemporary North American aboriginal communities retain elements of the above, which is how we are able to piece together their pre-contact views in an archaeology of psychological perception. Nevertheless, the stories of modern culture have infiltrated every aspect of current aboriginal life. Saskatchewan Cree poet Louise Halfe illustrates this in her poetry in which almost every poem has some reference to the dominant white group. Culture has changed. Our working definition of culture consists of all the stories told or having been told in a locale coupled with the results of their performance or enactment. Through contact, colonization, residential schools, education, and commerce, aboriginal people are slowly absorbing the internalizing the stories of the mainstream culture. Pockets of resistance occur as when traditional cultural healers attempt to maintain their practices or scholars piece together a picture of a world view from the past. Nevertheless, contemporary aboriginal culture with regards to mental health is a hodge podge of old views and those of psychiatry (Mehl-Madrona, 2010). When peoples mingle, their stories mingle, thereby co-mingling their cultures, and reducing the possibility of finding a “pure culture” to virtually zero. Waldram (2004) has written about the attempts of psychiatrists and psychiatric anthropologists to fit their definitions of culture onto North American aboriginal people. Mann (2007) tells a sobering story of anthropology defining a South American people as the most primitive on earth, holding the view that they had made no progress from the stone age, when actually these people were contemporary refugees, almost completely eliminated by the Bolivian government and landholders, who were not living their traditional way, but were moving in hiding and in fear of annihilation. Both Mann and Waldram make the point that scholars see what they want to see, that aboriginal people are a means to an end in scholarship, and that people are twisted in every which way to support theories that are probably unsupportable.
Within contemporary North America, indigenous writers are attempting to construct an indigenous theory of mind and mental health (Duran & Duran, 2000; Duran, 2006, Mehl-Madrona, 2003, 2005, 2007; 2008). The effort is to say, if aboriginal people had continued to develop contemporary theories of mind and mental health, what would those be? The challenge to psychiatry is to wonder if some of these theories might be more useful than contemporary psychiatric theory.
Aboriginal theories predictably focus on relationship and community over individuals and pathology. DSM is foreign to aboriginal thought which looks at every individual as unique, being the result of a unique combination of stories, location, family, relationships, and community. The homogeneity which DSM seeks and purports to have found is rejected. Treatment lies along the lines of restoring harmony and balance to relationships and communities and to providing people with better (more practical, functional, appropriate for the situation) stories to live and to be allowed to live through them. Therapies are spirit guided and relationships with non-physical beings are cultivated to aid in the healing process. This acceptance of magic and supernatural beings in healing is viewed as primitive and primary process thinking by mainstream psychiatry, rejected outright. Nevertheless, aboriginal thought has parallels in the social psychiatry of R.D. Laing, Loren Mosher, John Weir Perry, and others, who described superior results for the treatment of schizophrenia and psychosis using social environments instead of psychopharmacology. Additionally, the importance of community has been highlighted by the World Health Organization’s 20 year schizophrenia study, which found better outcomes in third world countries than developed countries, and mostly in relationship to the intact communities and social support found in India, Nigeria, and Colombia. The hearing voices movement is normalizing voices and voice management techniques over diagnosis of psychosis and psychopharmacology, mostly in the U.K., but to a more limited extent in North America. The positive benefits of elders for mental health problems are being described (Mehl-Madrona, bipolar, 2008), though funding is difficult to obtain for studies, since elders are not capable of being standardized or controlled (Mehl-Madrona, 2010) in the manner demanded for interventions in randomized, controlled trials. Indeed, the politics of evidence production works against elders, since valid evidence is obtained from studies in which all parameters are held constant (so the researchers believe) except for one. Obviously this methodology is best suited to study drugs. Consequently drugs have the most evidence to support them, even if the effect sizes are small.
The future of aboriginal world views in psychiatry is uncertain. Psychiatry has largely directed itself to biology as a means of explanation and treatment. Aboriginal world views explain human biology as a result of the enactment of story and the living of social relationships. Psychiatric epigenetics support these views but have not yet caught hold. Psychiatry attempts to explain unusual behavior as the primary result of damaged or disordered brains, while aboriginal thought seeks to explain brains as being formed by social environments and relationships, leading the primary cause of a disordered brain to be relational and social. Psychiatry has a huge pharmaceutical lobby behind it. In support of aboriginal world views is their sustainability. Drugs are far more expensive in developing countries than are human relationships. Certainly this is true on North American reserves and First Nations communities. Perhaps it is also true for mainstream North America – that the billions of dollars being spent on psychotropic medications would be better spent on jobs – for people to have therapeutic social relationships with those who suffer and are in pain, instead of physicians or physician extenders quickly prescribing very expensive medications of questionable value (see University of Ottawa meta-analysis of antidepressants and CATIE studies).
Certainly the mainstream dialogue of the Obama administration (or the Harper government) has focused upon providing services driven by existing philosophies to everyone (access to care) versus questioning the utility of currently offered services. Especially for aboriginal people, relationship based services may be more beneficial and cost-effective than disease-based services. I suspect this is also true for people of all ethnicities. I suspect that the current health care system is unsustainable in the sense that the headlong rush to develop newer, better, and different drugs is enormously costly, not to mention the manufacturing and marketing of these drugs. I suspect that a relationship model for mental health is far more sustainable and affordable in the long run (though not perhaps in the first three months for psychotic and mood disorders). What if the elders are correct, and that giving people intensive attention and care when they are in crisis is more effective than drugging them and seeing them monthly. What if intensive healing experiences (the enactment and psychodrama of ceremony) is more effective than the professionalism of white-coated doctors and nurses? What if keeping people at home in their communities is more effective (cost and benefit) than hospitalizing people and putting them in mental health care homes, away from family and those who know them. What if those who know us are far more beneficial without any training than those who don’t know us regardless of the depth of training? These are questions that contemporary aboriginal elders pose, which psychiatry ignores (the American Psychiatric Association rejected this year proposed symposia on indigenous models of mind and mental health and on psychiatrists working with traditional aboriginal cultural healers). The power balance currently allows such dismissal. Will this always be the case? I suspect that the health care crisis will have to get much worse for government to begin to question the value of the care we deliver instead of asking the question of how to improve access to the care we give. It will require a late-to-develop understanding that the care as we now deliver it, is unaffordable. It cannot be provided for everyone in either Canada or the United States. Currently Canada solves the problem with high taxes, long waits for elective or semi-urgent procedures, and long waits for specialist care. The U.S. solves the problem by denying care to the uninsured and the under-insured. However, the cost of providing care to everyone will be insurmountable. Here is where aboriginal models of mind and mental health might benefit contemporary society – in providing workable means of providing care than are sustainable and cost-effective, even more beneficial to reducing pain and suffering than the models that are currently dominant.

Love 2009

2009-01-02T23:22:00.001-07:00

My son is struggling with love. He's 15 years old and suffering deeply. I tried to get him to write poetry, but he wouldn't, so I wrote three poems about his situation. I'd love some feedback. I sort of like them. They seem to fit my son's suffering.

Lewis

Autumn Rain Storm

Outside, the rain tumbles down. The leaves
Wash away in its tribulations.
On the far side of the creek, woodchucks shiver
In dream dens – afraid of their homes being flooded
By the deep rain.
On the news, three houses float away on the river,
Disappearing in its raging, but,
Sitting beside my fireplace,
The falling, churning water seems so cozy.

The water tumbles -- submerging, rolling liquid. The rain’s
Great crushing noise is fearsome and powerful.
On the near side of the creek,
Rain is the wrinkled and dissonant tears of the aged,
The sky crying for the newly born,
The sadness of birth and death, the drum beat of the
Songs of death and terror – but in the end
It is just Rain.

Love is a Storm

I have been waiting for the calm in the storm, of
The hush in the pain and loneliness, when you sleep your
Wild dreams, one day closer to the cold graveyard of winter
While snow flakes drift down, circling the trees, in full view of indifferent
Ravens, preening their feathers, basking in the reds and oranges that
Hug the horizon. The sun has retired to its house in the West, the clouds
Appear to be burning; the vanishing tongues of flame, misty fog layers,
shredded pink
Clouds above the heavy glowing sky;
That peculiar smell of
Soon to be falling snow, the air pregnant with the potential of storm. Love
Is a storm waiting to be unleashed and a relentless quest for hate;
The clumsy and slow movements of the prey running out of options.

Ideas of Love

Our ideas of love
Slay us
In the blackness of night,
Like a procession of candles
In a moonless night
Or a single fire
On a moonless beach
Pretends to show us the Way

Instead we plunge into a dark void,
One candle in the darkness,
Perilous descent, along
A long sloping stone wall,
Searching for a name
For this place
That we called love

At the end is a massive silence,
A profound emptiness,
A circular darkness,
A cold and icy void
From which we must ascend
From which we must rescue ourselves
From which we must transform.

Creativity and Madness 2008

2008-12-30T02:19:00.003-07:00

I'm here at the Hilton Waikaloa on the Big Island of Hawai'i for the Creativity and Madness conference. I gave two talks about narrative concepts, one about the relation of narrative philosophy to Native North American philosophy, and the other about Narrative Neuropsychology -- how the brain comprehends, processes, stores, recalls, and tells stories. It turns out that stories activate virtually the entire brain. Stories can concatenate in the anterior temporal poles and therefore become smaller units of information for processing in the dorso-lateral preftontal cortex.

Anyway, let's stay in touch on these narrative ideas. They'll eventually reach the west cost of north america where they may chance the worldl

Christmas 2008

2008-12-23T23:28:00.002-07:00

Hello Everyone and Mele Kalikimaka (Merry Christmas),

Since my last post, I have been on Thom Hartmann's radio show in Portland, Oregon, which was really fun, since I got to speak for over an hour about Christmas depression. Then, an evening lecture at the New Renaissance Book Store in Portland. I'll be back in Portland, April 9-11, 2009, again on Thom Hartmann's show (April 10th) at the New Renaissance, April 9th, and speaking on Native American Health Disparities, Friday evening and all day Saturday.

Now I'm in Hawai'i. I got to sit at my new desk at Argosy University on Monday, which was fun, and I went surfing today, which was intimidating. I finished my new book, Narrative Psychiatry: healing mind and brain in a social world, and sent it to the publisher. I also got my papers graded for my last class at the University of Saskatchewan.

Today, I'm working on a book chapter about healing intergenerational trauma. I'm reflecting upon how children absorb the impact that events have upon their parents without ever having to experience these events. Residential schools had that impact. Generations of children who never attended residential school got the full impact through their parents. How does that happen? We learn the stories that our parents tell. We learn to perceive the world in this way. We then react to the world in this way and that resets our physiology.

Here's the abstract for the article:

Trauma to indigenous people has been more the exception than the rule during the era of colonization. Entire cultures were virtually decimated by disease (smallpox, hepatitis A, etc.) and forced to accept one sided treaties to avoid starvation. This phenomenon frequently occurs among Aboriginal populations who were forced to endure forced assimilation at the hands of European settlers. Among the British-derived colonies turned nations, the residential school phenomenon forged new waves of abuse that are still reverberating. The introduction of residential schools in the late 1800s emphasized the suppression of Aboriginal culture and institutionalized intergenerational trauma. The residential school experience led to increased feelings of fear, anxiety, helplessness, and increased maladaptive behaviors related to alcoholism, family discord, and high suicide rates (Bryant-Davis, 2007; Duran, 2006).

The concept of inter-generational trauma relates to trauma that is inflicted upon a subsequent generation by the behaviors engendered by the effects of trauma on the older generation. Intergenerational trauma results in the transferring of emotions related to a traumatic experience from one generation to another. This trauma can be direct through parents re-enacting the abuse they received upon their children. It can be indirect through the transmission of an expectation for being traumatized and behavior patterns that result from trauma without directly abusing the child. In this chapter, we will consider how inter-generational trauma arises, persists, and will ask how it has been healed and it can be further healed in aboriginal environments in North America and around the world.

2008-12-09T10:02:00.000-07:00

I want to tell the story of being kicked out of Canada, since it's one of the more bizarre experiences of my life, but it's also a message that Creator has a different plan for me. To my complete shock and amazement, on October 15th, I got a response from Canada Immigration in Los Angeles about my application for permanent residency. I had just been declared "criminally inadmissible" to Canada because of a traffic violation in Arizona in 2005 for which I paid a $200 fine. I had a misadventure with a red light late one evening when no one else was around. I didn't realize that the U-turn green arrow (which always followed the red light) was turned off after 9:30 pm and I habitually turned, only there wasn't a green arrow like in the daytime and a cop was sitting there and bingo! Little did I realize this would someday make me a "criminal" in Canada. The ticket dropped from my record after three years and I have a clean driving record now in the U.S. What's even more funny was that the same Immigration people knew about this from the time I entered Canada and it was no big deal for me when I got a work permit in 2005 and in 2007. Apparently policy changed, or this is what I was told by a Saskatchewan provincial judge with whom I became acquainted. The new policy as of July 2008 is to treat all traffic stops in the U.S. as "felonies" in Canada. Strange.

So that's a long way of saying I had to rethink my life plan. Besides focusing more on teaching rather than clinical practice (I'm teaching psychology now at Argosy University and anthropology at Johnson State College), I'm throwing my creative energy into the newly formed Coyote Institute (for Studies of Change and Transformation) which is a way to blend and re-energize indigenous wisdom with the post-modern world. Anyway, our two main current projects are 1) the Hahokah Project, which is to create a healing circle in every living room in the world, and 2) the Traditional Healing Project, which is to create a network through Second Life of traditional healers from around the world who can connect with each other and can also be reached by anyone interested in traditional cultural healing. We're slowly building all this at www.coyoteinstitute.org.

Lewis

2008-12-08T16:25:00.002-07:00

Dear Anyone whose Reading,

I'm restarting my blog after several months hiatus.

What's new!

We've started Coyote Institute (for Studies of Change and Transformation) in earnest!. How exciting. We're a Mississippi Corporation and are applying for non-profit status. You can learn more about what we're doing on the google discussion groups for coyotemedicine and coyotewisdom. We're planning a non-hierarchical organization with a governing council of seven people. In a very real sense, we're trying to build a tribe and are fostering the growth of dens all over the place. Before we achieve non-profit status, we can still accept your help through another non-profit who's nursing us along from pup-hood to adulthood.

Also, my website has changed to www.mehl-madrona.com and, as well, there is a developing website for Coyote Institute at www.coyoteinstitute.org.

Coyote Institute has two initial projects (and more as the various dens dream and plan and vision and sing and dance):

1) Hocokah Project. We want to encourage everyone everywhere to be part of a healing circle. We will have information on the Coyote Institute web site about how to start a hocokah, how to manage a healing circle, how to have leaderless leadership, and more. We will have a discussion group for working out difficulties and reporting successes, a place for collecting stories of results and outcomes (also known as research), and a directory of circles that people can join.

2) Traditional Healing Network. We are seeking to create a cyber-community for healers from all around the world, so that healers can communicate with each other, can network, can be found by people anywhere who are drawn to their healing system. We envision healers "studying" themselves, a break from the usual way they are studied by anthropologists. By that we mean healers reflecting upon their approaches, what they do, how it works, why it works. I am especially interested in diabetes and in so-called "mental illnesses", but others may have other interests. We are considering a software platform called Second Life for managing these connections.

I'm personally really interested in re-visioning research so that people themselves ask questions of relevance in collaboration with each other, as opposed to our current academic framework.

Of other relevance is my move to Argosy University in Honolulu, Hawai'i, where I'll be the Director of their Psychopharmacology Program and also an Associate Professor. This January I'll be teaching Neuropsychology, Quantitative Inquiry, and Stats Lab. In the summer, I'll be teaching Narrative Psychology. More later.... I'm getting winter tires and they just got placed onto the truck and it's ready to roll.

Lewis

Bugs

2008-06-07T05:30:00.003-07:00

I am sitting in the shadows of Mt. Mansfield, in Stowe, Vermont, waiting for my son to wake up. We're going to a sweat lodge in Weybridge, Vermont, that we built last weekend. This will be the second time this lodge has been used. We'll leave at 0930, so I better wake him up at 0900. It's 0830 now.

I just finished three intensive retreats (one partial week), the other two, a week, and more than a week. I wanted to talk about the power of community for healing, the way that we have so much more power for healing. When we had three people together it was more than twice as powerful as two people. Five people were even more powerful. We forget that in conventional medicine when we try to keep people alone in little rooms with us.

I wondered about the kind of world we would have if medicine were more like intensive retreats than it is. We would need to make a big shift in how we think about illness and practice medicine. Current medical practice is primarily aimed at doing whatever it takes, mostly with drugs and surgery, to create a physiological state in which we can’t see physical evidence of disease and the person stops complaining of symptoms. It’s an “anti;” approach. We use antibiotics, anti-depressants, anti-psychotics, analgesics, anti-anxiety agents, etc. Most of our classes of medications can start with the letter “a”. How would medicine look different if we saw illness as an aspect of life, part of the human stories that we live, and not necessarily an external evil attacking us that needs to be destroyed or attacked back. I suppose our current metaphor is the immune system, in which natural killer cells absorb invading bacteria. What this model fails to take into account are the many healthy relationships we maintain with micro-organisms. The environment is not as unfriendly as contemporary medicine imagines. I suspect that what we do with our antibiotics is to kill our friends and strengthen our enemies, perhaps a parallel to what has happened in the various Gulf Wars.

What amazes me is the current terror people seem to feel about germs. I'd like to stimulate some discussion around this. I know people who claim to have had various infectious that my medical training says is impossible. Some have been cured with homeopathic injections, others with months of intraveous antibiotic therapy, others with ceremony and ritual and no antibiotics at all. I think homeopathics have other effects than just ridding the body of germs, some of those effects being quite profound. I have injected Traumeel for joint problems and have been impressed with it and/or the placebo effect associated with it. I got some old ladies in Tucson off steroid injections (which I know are bad for joints) and onto Traumeel injections. Was it placebo or Traumeel? Only God Knows and she's not telling.

Anyway, does anyone know about this approach to illness of using cotton balls to look for germs and then devising remedies energetically (I assume they use a computer system that puts the desired energy into solution) though I don't know. Dr. Schultz is one of the people involved and then there is a person named David in Colorado who makes remedies also. I probably should have gotten more proper nouns from my friend, but didn't.

So here's my question, to myself and anyone reading this, and I found out, as I mentioned in my last post, that some people do read this, because Mothering Magazine read my blog, which actually really touched me. When are germs good and when are germs bad?

I suspect there are some really bad germs that are probably human created, like HIV or Ebola virus. I suspect we have done something to the environment to facilitate the creation of super bad bugs, because I don't think nature would be so stupid as to create something so lethal.

But what about worms, parasites, spirochetes, etc.? We know that children in Third World countries have virtually no asthma or juvenile rheumatoid arthritis. The argument is that their parasites shift their cytokine balance in such a way that they don't get these conditions because the resources are needed to fight bugs and parasites. However, children in New York City, which I suspect is the most germ-fearing city on earth, have tremendous high rates of asthma and JRA. Is it actually healthy to avoid bugs or does it hurt us in other ways? Are bugs our friends?

That's what I meant by the "anti" paragraph above. It seems we're against all life but our own and perhaps our own lives require the lives of our invisible friends to be whole. What if we need germs to be well! My New York friend talked about her doctor seeing spirochetes and staphyloccus in her live blood cell analysis. I had trouble believing that given my training. It seemed that she would be dead if she spirochete or staphylococcal septicemia. Nevertheless, I could believe that immune cells could float around in blood that have encountered these critters at some time and have memory of them. But that's not what the live cell analysis people were claiming.

Leo Omani, who is a healer on Wahpeton Dakota Reserve in Saskatchewan tells his children to tell their children to eat dirt because it will make them healthy. A lot of elders in Saskatchewan believe in the healing power for young children of eating dirt. Could dirt have had protective factors that made it less likely to get TB or smallpox?

I suspect that most of what we do with our medicines is kill the friendlies and encourage the growth of the super-bad-bugs. I know that the death rate from infection began to decline in 1856 with the improvement of plumbing and its implementation and that the slope for the rate of decline didn't change with the introduction of antibiotics on a widespread basis. The argument would be that those we save with antibiotics are balanced out by those we kill with antibiotics (Stevens-Johnson Syndrome, anaphylaxis, overgrowth of Clostridium, etc. etc.). I never cease to be amazed at how physicians hand out antibiotics. I suspect it would be better if they were over the counter like Mexico so that everyone could buy penicillin, ampicillin, etc., and might stop there, because the physicians hand out samples of things like Levaquin or even more powerful new drugs. They do this for conditions that probably won't respond to antibiotics anyway, though all patients expect them now. The name says it all -- "against life."

My friend in New York hesitates to even shake the hand of those who might have bugs. She wants everyone she knows to get checked for bugs and treated. Of course, the treatments might be helpful independent of the bugs, and perhaps homeopathy played a large role in her recovery. I don't know.

I do find my New York friends who are afraid to walk on grass for fear of bugs somewhat amusing. What a state when people are afraid of grass. (It might have deer tics hiding in wait to ambush the unsuspecting humans).

But what about all the bugs who do abound -- hepatitis C is an example of a virus that deserves respect. Those bugs can cause dreadful disease, though I know people who are living well with hepatitis C and have learned to accomodate it to them, and them to it.

Thoughts?

Narrative Medicine and the Audience

2008-05-21T06:43:00.002-07:00

I am in Stony Rapids at the top of Saskatchewan. I just took off the article from Mothering on Hypnosis and Birth because I thought they had published it long ago and it turns out they haven't yet published it! They saw it up on the blog and asked it to be taken down. What amazed me was that someone actually read my blog (e.g., the editors at Mothering). There's an illusion I suppose that no one is out there. I'll have to check with them if it's ok to leave up the original paper from the American Journal of Clinical Hypnosis 2004, but I suspect that it is. My apologies to mothering. And thanks for giving me the experience that someone actually reads this blog.

That brought my awareness to a message from Renae on Coyote Wisdom discussion group. She was writing about Bakhtin's perspective that all dialogue involves an audience. She wrote about Bakhtin's perspective on our internal, silent dialogue always being for someone. She brought my awareness even further to the importance of the audience in what we do. In our most silent and alone moments, isn't every one of us aware of being watched. Some would say we have created an imaginary audience. Other pre-moderns would say the spirits and the ancestors are always watching us, which is a feeling I have -- of my grandparents and other spirits watching what I do, which, of course, makes me accountable to my perception of what they would think of what I am doing.

So the stories that we perpetually live are being lived for someone. Who is our audience? Who are these "ghosts within" who watch what we are doing and planning. I think what Bakhtin was getting at was the way conversations are memoralized. We don't just store the story. In order to properly store the story, we must store the context in which it occurred and the audience who heard it. Whenever I remember with language, it seems that I am telling a story (silently, of course), but to someone. When I remember without language, then I feel what happened to me, but it seems that there is no way of changing or resolving without language. The non-language parts of the story are immutable without the words themselves which allow us to change the tone. So when I start to tell myself a story, I use words and their associated images and I do imagine an audience. Sometimes it is a friend. Sometimes I have the feeling that my grandfather is listening. Sometimes I imagine some element of the Greatest Mystery being aware of me and my tale. Always there's someone.

So when Renae wondered how changing the audience would change the story, that became central to my meditations today. When a person enters our office, they come not only with multiple stories begging to be heard, but also with multiple audiences who listen as well to these stories and influence their telling. In our interviews and discussions, we need to be more conscious in asking about the audience. Perhaps, we should ask, who do you think about when you are alone? Do you ever have the experience of feeling that you are rehearsing what you will say to someone in your mind? We'll have to be careful because the experience of what actually happens within us sounds psychotic to the conventional psychiatric mind. To me, I suspect voices in part arise from these internally constructed imaginal beings who eventually become able to talk back to us or comment on us. When we lose the story that goes with them, they become "as if disembodied." The voice loses its context and remains to torment the individual. Psychotic voices, by the way, are almost always disturbing and critical these days. Once upon a time, perhaps they were more spiritual.

More later....

Where I grew up!

2008-05-16T10:09:00.001-07:00

I thought I'd start a series on my background, since people wonder. Here's where I was born. More images to follow next time i get the time to post. This was mostly about figuring out how to put up images in the blog.

Lewis

American Psychiatric Association 2008

2008-05-06T19:40:00.002-07:00

Dear friends,

I'm here in Washington, D.C., at the American Psychiatric Association's 161st annual convention. What a trip! I now realize that anything besides drugs is considered alternative medicine. I do remember when family therapy and community therapy was considered ordinary. Now it is alternative. Doing anything besides prescribing drugs is alternative.

It is so interesting to speculate upon their story, their world view -- materialist, yes. Contextualist, no. Almost solipsistic in their sense that everything arises from genes in brain and nothing is environmental determined. It's fundamentalist in the sense that it insists upon a view despite contradictory evidence that the brain develops and is shaped and formed by a social environment. In its materialism, it is infinitely afraid of magic. If you believe in magic or spirits, you are crazy.

So here's the next course I am teaching at Johnson State University in Vermont:

Syllabus: Multi-cultural Traditional Healing
Johnson State University, Summer 2008
Instructor: Lewis Mehl-Madrona
Required Textbooks:

Coyote Healing: Miracles from Native Medicine
By Lewis Mehl-Madrona
Contributor: Larry Dossey, M.D.
Published 2007Inner Traditions
Medical / AlternativeMedicine
256 pages
ISBN:1594770085

Distills the basic principles used by Native American healers to create miracles. Explores the power of miracles in both traditional Native American healing and modern scientific medicine. Cites numerous cases in which people whose conditions were deemed hopeless were miraculously healed. Enables readers to start their own healing journey through the exploration of purpose, meaning, and acceptance. By the author of "Coyote Medicine". Native American healers expect miracles and prepare in all possible ways for them to occur. In modern medicine, miraculous recoveries are discarded from studies as anomalous cases that will taint the otherwise orderly results. Yet this small group of ?miracle? patients has much to teach us about healing and survival. "Coyote Healing "distills the common elements in miracle cures to help people start their own healing journey. Looking at 100 cases of individuals who experienced miracle cures, Dr. Mehl-Madrona reveals what he learned from both his own practice and the interviews he conducted with survivors about the common features of their path back to wellness. Survivors found purpose and meaning in their life-threatening illness; peaceful acceptance was key to their healing. "Coyote Healing "also tells of another kind of miracle: finding faith, hope, and serenity even when a cure seems impossible.

Papers to be posted on the class web site about Eurasian healing/shamanism, translated by Andrei Vinogradov.

Preview this book

By Uwe P. Gielen, Jefferson M. Fish, Juris G. Draguns
Contributor Uwe P. Gielen, Jefferson M. Fish, Juris G. Draguns
Published 2004Routledge
Healing
433 pages
ISBN:0805849246
Emotional, as well as physical distress, is a heritage from our hominid ancestors; it has been experienced by every group of human beings since our emergence as a species. And every known culture has developed systems of conceptualization and intervention for addressing it. The editors have brought together leading psychologists, psychiatrists, anthropologists, and others to consider the interaction of psychosocial, biological, and cultural variables as they influence the assessment of health and illness and the course of therapy. The volume includes broadly conceived theoretical and survey chapters; detailed descriptions of specific healing traditions in Asia, the Americas, Africa, and the Arab world. TheHandbook of Culture, Therapy, and Healingis a unique resource, containing information about Western therapies practiced in non-Western cultures, non-Western therapies practiced both in their own context and in the West.

Class outline:

Friday, July 25th: Overview of North American traditional healing practices. We will follow the basic structure of Coyote Healing to explore how traditional Northern Plains North American healers work. We will look at stories of miracles and how they happen. We will explore the concept of the medicine wheel and each of the four directions. The experiential component of the time will focus on a guided imagery around the medicine wheel, exploring our four inner directions.

Saturday, July 26th: We will explore Eurasian shamanism and its relationship to other shamanic practices. Our text will be an unpublished manuscript written by Russian anthropologists and ethnographers and translated by Andrei Vinogradov who will be joining us for our online discussions after the weekend. In the morning, we will look at what happened to shamans under the Soviet system and how things changed when the Soviet Union collapsed. We will see how this influenced contemporary shamanism today. We will look at the similarities of shamanic practices across regions and the range of shamanic practices that are possible – sucking, feathering, fanning, blowing, smoking, etc. We will cross a range of Eurasian practices based upon the reading and will explore what is common and what is unique about traditional healing in a range of Northern Eurasian regions.

Sunday, July 27th: We will consider the following topics:

Culture and the Origins of Psychopathology
psychopathology, cultural evolution, Pongids

The Role of Culture in Definitions Interpretations
African American, asthma, Medical Anthropology

A Biopsychosocial Perspective on Crosscultural Healing
placebo effect, Psychoneuroimmunology, classical conditioning

The Role of Culture in the Treatment of Culturally Diverse Populations
African Americans, Young Rivers, Asian Americans

Culturally Oriented Psychotherapy with Refugees
refugees, Asian, mental health

The Role of Dance in a Navajo Healing Ceremonial
labanotation, Navajo Nation, Navajo Music
more »
The Therapeutic Aspects of Salish Spirit Dance Ceremonials
Coast Salish, British Columbia, Spiritualist healers

A Gendered Exploration in Puerto Rico
Puerto Rico, mental health professionals, Spiritist

Theories and Methods
qigong, acupuncture, Taoist

A Criteriabased Metaanalysis
qigong, alternative medicine, hypertension

Psychoanalysis and Buddhism
Transpersonal Psychology, Tibetan Buddhism, contemplative disciplines

Naikan Therapy
Morita therapy, Taijin Kyofusho, Naikan therapy

Indian Conceptions of Mental Health Healing and the Individual
Ayurvedic, dharma, moksha

Problems of Insight
Angola, Yoruba, Babalawo

Native Healing in ArabIslamic Societies
Qur'an, jinn, dhikr

The online discussion group will continue until the end of the term and will involve discussion of the above topics. Students will be required to post one long and 5 short posts each week. A long post consists of a full computer screen. A short post is responsive and of any length.

The written requirement for the course is to create a document worthy of posting upon the class website. Students will dialogue with the instructor about quality until a mutually satisfactory document (or movie, or slide show, or multi-media presentation arises).

Students are also required to keep a diary or a blog about how their reactions to the reading and how it changes them or their concepts and what they have learned.

what traditional elders believe about mental health training

2008-04-23T22:09:00.002-07:00

Here's my latest paper that I've just revised. I'd sure appreciate some feedback or comments.

Lewis

What Traditional Indigenous Elders say about Cross Cultural Mental Health Training

Lewis Mehl-Madrona, MD, PhD
Departments of Family Medicine and Psychiatry
University of Saskatchewan
Saskatoon, Saskatchewan, Canada

And

Southwest College
Santa Fe, New Mexico, USA

Address communication to:
Dr. Mehl-Madrona
P.O. Box 9309
S. Burlington, VT, USA, 05407
808-772-1099
Fax: 306-655-4894
Email: mehlmadrona@gmail.com

Abstract. As part of the process of creating a cross-cultural mental health training program, a group of 19 traditional healing elders from both the United States and Canada were asked their opinions about the core values and principles that should be part of all mental health training. This exploration was part of an intuitive inquiry process in which the author was the subject and the elders, co-investigators, who helped him to explore his biases and those of the various cultures in which he was trained and practiced. The paper is structured to match the author’s experience beginning with the introduction he gave the elders about himself and proceeding with a story one of the elders told him in response to his question. Conversations with the elders were open-ended, in a narrative inquiry format, and were summarized using modified grounded theory techniques to explore what was common to all discussions. Summarizing principles that emerged were presented back to the elders iteratively until 12 unanimous concepts or principles resulted for consideration for use in the education of people who will provide services to indigenous people. While none of these principles and ideas are necessarily new (in the sense that they have not previously appeared in the literature), their joint presence is new and the process with elders through which they emerged has not previously been described. Implementing these ideas would change the way that psychiatry, psychology, and social work are taught and practiced. It is hoped that their assemblage in this form can impact mental health training programs to include more culturally appropriate concepts and practices for indigenous peoples. These ideas may also be relevant to the training of all human service providers who work in indigenous communities. A community-based, cross-cultural health and healing program was developed at Southwest College based around these 12 ideas.

A number of authors have commented upon what future mental health practitioners should be taught to be effective and appropriate with indigenous people, though rarely have traditional cultural healers been asked for their views. Equally rarely have the knowledge keepers of indigenous communities been asked how they define mind and mental health and what would properly constitute mental health services from their points of view. Multiple perspectives exist within any indigenous community, ranging from highly Christianized to a Western medical perspective to traditional cultural healing. The focus of this paper was to explore what a relatively diverse group of traditional cultural healers believed important as attributes for mental health providers to hold or principles that should guide training. We also wanted to explore what mental health services meant to them. This work was done in preparation for developing a cross-cultural training program for human service providers that would include elders as community mentors and adjunct faculty on equal status with academically trained faculty. Our goal was to summarize the core values and principles needed to train mental health providers to work in harmony with traditional cultural healers. The term indigenous will be used in this paper to refer to the people who have lived in a place long enough to develop local knowledge and practices about that place, though they might not have been the original inhabitants of that place (for example, Dene in Arizona are indigenous though they have only been there from about 1100 A.D.).
Though much anthropological literature exists related to indigenous healing, relatively little has been written to guide mental health professionals to work effectively in indigenous contexts. The literature that does exist includes a discussion of values in A Gathering of Wisdoms, (Swinomish Tribe Mental Health Project, 1991). An especially helpful chart describes what mental health workers can learn from Native American culture. The Sacred Tree describes the integration of western and indigenous therapies as do articles by Michael Tlanusta Garrett (Garrett & Garrett, 1994; Garrett & Pichette, 2000). Garrett discusses seven practical recommendations for effectively counseling Native American clients. Duran (2006) further amplifies the problems that white practitioners may have when they work with Native American clients. Some of my elders would argue that the European notion of counseling or psychotherapy is inappropriate and so flawed as merit abandonment.
Since I work collaboratively with traditional healers in much of my clinical practice, I have had extensive discussions with them about what students should know. We have discussed trainees who are unacceptable and trainees who are desirable. This paper is about their views. I will attempt to present this in an indigenous way, first by situating myself, then by telling a story, and then by explaining my methodology, describing the elders and telling what they said, and ending with a story to dramatize the conclusions (as they would do).
In my work with indigenous communities (Mehl-Madrona, 2005), I have repeatedly observed the repetitive overuse and failure of the “one cause-defective brains” model of mental health. I have watched new graduates appear in communities armed with a vast array of knowledge from their medical or graduate training. They are surprised when no one comes to see them. James Gustafson (1976) wrote a paper on the relative immaturity of Lakota people which made them unable to use psychoanalysis as a healing method. He failed to grasp the vast cultural differences that led people to suspect anyone who sat silently behind a couch as a bit strange and unhelpful. The blank screen was not a part of indigenous socialization. Talking to someone who gave no feedback held no interest to the people.
Modern professionals are attempting to educate indigenous people in the current model of mental health. We teach them to come alone to appointments. Worse, neighbors bring a child for his or her appointment with no knowledge of the situation at school or at home. The child is delivered to the professional to be fixed. Drugs are expected. Traditional healers, or knowledge keepers in relation to health and disease, would immediately suspect a paradigm that excluded the community. Elders consistently point to the need for community involvement in healing and well-being (Linik, 2004). They believe that indigenous people are embedded in families. Elders have told me that disease exists in relationships and not within people (Mehl-Madrona, 2003); therefore addressing disturbed relationships also addresses disease. Mental health professionals have largely ignored the potential benefits of local knowledge for securing or improving the life situation of the local population. In order to be able to correctly assess the general significance and particular relevance of local knowledge in a given situation, it is important to see the context in which that local knowledge is located. Wittgenstein (1953) wrote that, for all our claims about 'things', all our theories must be tested in practice.
Duran & Duan (1995), Colmant et al. (2004), and Lux (2004) stress the cultural changes brought about by colonization through its impact upon people who attended residential schools. The devastating impact of the residential schools is largely undiscussed in conventional psychology circles. In a semester class on aboriginal mind and mental health (see http://groups.google.com/group/aboriginalmind) at the University of Saskatchewan (which has almost 10% aboriginal students), none of my non-aboriginal senior students initially had any understanding of residential schools or what residential schools had done to the people. These students were preparing to enter graduate programs in psychology and social work. Lux (2004) has written the most eloquently about the residential school experience in which children were removed from their homes at ages 5, 6, and 7, placed in overcrowded “schools”, mostly operated by the Anglican or Catholic churches, forced to work to maintain the school, disallowed any contact with their families and cultures (including punishment for speaking their language), and often physically, sexually, and/or emotionally abused. This practice lasted from the 1880s well into the 1970s (Lux, 2004). Currently, lawsuits have resulted in claims being paid by the perpetrators and the government of Canada to First Nations people, but these monetary payments do little to change the effects of residential schools.
In my work on reserves, I have largely abandoned the individual appointment model. I have stopped expecting people to come to buildings for appointments at preset times. I go out to the people, to encounter them where they are – in their homes, others’ homes, grocery stores, tribal offices, powwows, parking lots, schools, and more. I include relevant family and community members. I have recognized that many of the problems we address are related to lack of jobs, housing, and meaning. The people’s meaning and purpose have been lost. In Canada, the Indian Act, enacted in the 1870s and continually revised and modified until the 1960s, denied indigenous people the opportunity to own land, run businesses, or to be educated (Lux, 2004). It gave the Indian Agent authority to control virtually every aspect of an aboriginal person’s life, including marriage; sexuality; and religion, Traditional ceremonies were made illegal. A similar act existed in the United States, though the U.S. did not deny its native peoples the right to own property or to be educated. Charles Eastman was an Oglala man who attended Dartmouth College and then Boston University School of Medicine and served as the physician for Wounded Knee for 40 years from the 1880s to the 1920s, writing 19 books about his people, many of which are still in print (Eastman, 2003; http://en.wikipedia.org/wiki/Charles_Eastman). His education would not have been possible in Canada.
In Canada, whether they wished to join the modern world or not, all doors were shut. Marriage to a non-Indian ended the person’s Indian status. The only means to gain an education was to become a minister or a priest. The economic differences between the haves and the have-nots grew larger by the year. Today, aboriginal people are the poorest in Canada. Since real estate is a primary way wealth is defined, the act of preventing them from owning real estate while the Europeans claimed the desirable land guaranteed a culture of despair. Medications do not necessarily address that despair. Through its avoidance of the indigenous knowledge about the importance of meaning and purpose in maintaining health, psychiatry and psychology fail to teach their students about the social determinants of mental illness and about community interventions that could address these matters. Community interventions are largely relegated to social work by physicians and psychologists. Current mental health efforts have not sufficiently mobilized local knowledge for mental health. Current practices aspire towards "authorities" who are largely external, thereby restricting the establishment of competent leadership and sustainable structures in local communities for promoting mental health. List most common mental health problems in indigenous populations and similarity to other populations.
Indigenous people have survived in their unique, local environments and have developed extensive knowledge systems that relate to those environments, including how to manage the apparently universal concepts of pain and suffering, though not all peoples define mind or mental health. Because the term "local knowledge" refers to a dynamic process of acquisition and integration of contemporary information and experience, it is difficult to effectively apply those aspects that relate to pain and suffering within biomedical definitions of mental health. However, as we discuss how to apply local knowledge to mental health and addiction problems, it is evident that the overall community is often hampered by deteriorating social structures, thereby forcing its members to look after their own individual needs and survival, undermining traditional values and stories that put the needs and survival of the group above that of the individual. This leads them to the biomedical paradigm of the individual seeking treatment in isolation from others. This situation in many communities does not support the application of existing knowledge. Due to the fact that knowledge gained through oral traditions, apprenticeship, or life experience is no longer fully and systematically used, we now have a "fragmented" local knowledge system (Mersmann 1993). A consequence of this situation is the difficulty of local communities and individuals to actively integrate external mental health practices into the local knowledge system in a way that maintains its integrity.

Methods

I defined elders in the manner suggested by my colleagues at the University of Saskatchewan (James Waldram (1997) and Valerie Arnault-Pelletier (2008)) as people performing actions within communities to reduce pain and suffering, recognized by sufficient members of their community as having the skills and training and experience necessary to do so, and recognized as embodying the traditional values and beliefs of that community.[1] Healing elders typically use the historical healing practices of their family/tribal group or community. Typically when a community member is asked about an elder, they would acknowledge that this person is respected by many even if they look to a different elder for guidance. Most indigenous people have one or more elders upon who they rely for guidance and healing – sometimes family members, sometimes not. The elders participating in this project were those with whom I had already spent many hours, attending their ceremonies, sharing clients with them, and watching them work. These pre-existing relationships provided a crucial foundation for my being able to sit with them and discuss how mental health practitioners should be trained. These elders were regularly approached by members of their community for healing and prayers and were recognized as spiritual people.
Gaining knowledge from an elder differs from conventional research practice. I gave each elder tobacco, sometimes colored cloth or prayer ties, and usually a gift each time I sat with them. This acknowledged their teaching me. I was the subject who was trying to learn. Unlike a conventional study with multiple subjects and one researcher, I had one subject (me) and multiple researchers (teachers). These elders found the usual research format of consent forms and confidentiality and data collection highly amusing and would never participate in such nonsense, as one said. Rather they were my teachers and were satisfied when I could repeat back what they had said correctly. They were offered co-authorship, but all declined, believing that writing papers was trivial and should be left to me as “my thing.” “This was your journey,” one said. “Now you tell your people about it. Our people already know all these things.” The beginning of any journey in indigenous communities is to situate oneself. Who am I and where do I come from?

Situating Myself.

I am a multi-cultural person, born in southeastern Kentucky near the Tennessee border. I came from a long line of Cherokee people who escaped Andrew Jackson’s Trail of Tears, forced march of our people to Oklahoma in 1836. My ancestors hid in the Appalachian Mountains of Kentucky and slowly assimilated with the white culture, primarily Scottish, also called “hillbillies” – the people famous for blue grass, fiddle playing, and sometimes moonshine making. My father’s people were the result of the Fur Trade – a combination of French Canadian and Oglala from the Wounded Knee area of South Dakota. My mother and father met at a USO dance in Kentucky where the U.S. Air Force sent my father.
I grew up within my maternal grandmother’s Christianity, which later I discovered to be so far from conventional as to be Cherokee in disguise. For example, she adamantly maintained that Mary was more powerful than Jesus because Mary gave birth to Jesus. She saw Mary as the chief of the women and Jesus as the chief of the men. Her other quirks taught me about culture, assimilation, and slowly but surely led to my interest in indigenous healing and mental health. I come from the generation in the United States who began to reclaim our heritage and culture after our mothers’ generation had eschewed all connections and struggled to fit in as white. For most of my generation, out fathers were absent or dead as was mine. My life events and my patients' experiences forced me to address the question of what is healing and what is the proper calling for psychology. So little of what I observed with the traditional healers matched what I was taught in my training. So much of it went against the assumptions and values of the mainstream. The knowledge of the healers was dismissed as unimportant and not relevant by my professors in medical school, psychiatry residency, and psychology graduate school. As I discussed this with my elders, I was told that they would work with me because I shared their core values. However, they said they would have nothing to do with me were I to to operate from the values and practices I was learning in my mainstream education. This posed a problem, since we needed to consider how to bridge conventional training with traditional cultural healers and train students to recognize this bridge regardless of not having grown up with indigenous people or in an indigenous community.

A Story

In keeping with the indigenous style of presentation, I will relate an example of a story about being multi-cultural in the modern age and about one of the elders who helped me struggle with these concepts. When I entered the tipi, Old Ben was in the midst of a story. He was always in the midst of a story, having melded his life into the art of never being caught starting or ending. Old Ben was surviving into the 21st century in the patch work way common to many contemporary shamans. On the weekends he led ceremony. During the week he worked as a printer. Like many modern day Native Americans, Ben’s life context was even more complex -- he was a Navajo - Lakota mix living in Hawaii. He had come to Hawaii years before with the military, had started school while serving at Hickam Air Force Base, and had stayed. He had planned to go back to South Dakota or Arizona where the seasons changed, but never did. He still talked about moving back home to the reservation, though he probably never would.
Like a true resident of the Rainbow State of Hawaii, Ben borrowed freely from all cultures at will, changing the names to fit his audience. Ben’s knowledge was a priceless and unique blend of everything that had ever crossed his awareness, packaged through his gift of semantic mutation. His consciousness treated stories in the way that viruses treat DNA. As he heard and recalled stories, he substituted, deleted, and recombined various parts of the stories until something brand new resulted never before seen or heard. Maybe all healers work this way.
Ben was telling a story about an ancient one who gave up his voice so that his family might never go hungry. This man was a great healer and storyteller but was perpetually poor. A spirit offered him a trade -- his voice and his ability to heal for prosperity. “The healer’s wife was overjoyed,” Ben was saying. “Finally she would always have meat on their table and the things in life which she felt she had deserved for all those many year that she had lived with the healer. A deer brought itself to their lodge and lay down for their food. The choicest roots began to grow behind their lodge. Barren bushes grew berries.
“Things were worse for the healer than he could have ever imagined,” Ben continued. “He had not realized how many little things in life that we do are healing. He could not make the softest touch for these are often more healing than the grandest ceremony. He could not reassure or comfort his wife and children. In fact, there was little he could do, for most of what we do in life is healing to someone or something. “Unfortunately, his wife soon grew tired of prosperity for what is wealth without love? What is prosperity without comfort or joy? What is the satisfaction of hunger and thirst without gentle companionship? Soon the healer and his family were more despairing than they had ever been.
“This is sort of a variant of ‘the grass is always greener,’” Ben said. “The man was now helpless for he had lost the capacity to heal himself and that is what makes us human. His wife vowed to help him but what could she do? She resolved to take him to all the best healers even in distant lands, to whatever it took to make thing right again.”
It was a motley bunch inside this tipi set in the tropics of Volcano, Hawaii, where Ben held court. He came down the volcano each morning to Hilo on the weekdays and stayed at his house on the slopes during the weekend. People found him, the same way they found Papa, the local Hawaiian healer or other kapunas (teachers) and kahunas (healing elders) that the local people respected and used. Today the tipi that sat in his backyard contained a blind radio announcer from Kona, This was a true cross-cultural dialogue about health and well-being. I wished all my students could have been there.
The kind of cross-cultural dialogue that existed at Ben’s house is rarely found within psychology and psychiatry. Medicine presents a global technology that is proposed to be universally true because of its basis in “science.” The restrictions of contemporary “scientific psychiatry or psychology” are rarely discussed. Mehl-Madrona (2007) describes how treatment is always context dependent, working or not working in accordance with its fit into the master narratives and beliefs of the people who are being treated and requiring the development of a shared story for how people work together to facilitate wellness. While this is less obvious for an acute surgical procedure, it is crucial for recovery from surgery and becomes all the more obvious, the closer one moves to the realm of emotional suffering. Modern medicine and psychology are relatively indifferent to the keen observations and analysis of indigenous knowledge keepers regarding health, illness, and well-being. It is fairly limited by its insistence on the randomized, controlled trial as the ultimate basis for knowledge production and to its preference for treatments that are not individualized or relational.
Many believe as does Duran (2006) that one must be raised within a culture to truly understand it. Others believe that one must speak the language to understand a culture. Laubin & Laubin (1957) influenced the preservation of Lakota culture without being raised within that culture as did Adolf Hungry Wolf' (2006) for the Blackfoot people. Some who were raised within Native culture nevertheless, adopted the colonial knowledge system (Duran and Duran, 1995).
My method of intuitive inquiry began with an explanation of what I believed and had experienced about the topic, then proceeded to explore what others believe and have experienced in a review of the literature. Then I engaged in an inner dialogue, highlighting what changed as a result of my research and noting any intuitive breakthroughs. Then I returned to the literature to explore how the new perspectives relate to existent theoretical and empirical literature and to the greater context (Braud & Anderson 1998, 2005). Then I had my discussions with the elders and wrote down after each meeting what I remembered about our discussions (note taking would not have appropriate). Modified grounded theory within this framework was used to guide my reflections upon the discussions and dialogues held with the elders. Notes using theoretical memo writing were made in the margins; these notes were summarized through theoretical coding and laid out along with my reactions to the discussions. The categories that emerged were taken back to the elders for further discussions. Through an iterative, back and forth process, we all agreed upon 12 categories stood out in all of our discussions.
The elders who engaged in the dialogue about these concepts are summarized in Table 1. I used an open ended, narrative style dialogue with each elder over several meetings. The general topic for discussion included their views on 1) mind, 2) mental health, 3) the disorders they recognize of mind and mental health, 4) who should be involved in healing mental health problems, 5) what should they know, and 6) how they should be trained? Of course, the elders said what they wished. I had previously been trained by several of them in the “art of listening,” which is crucial to studying with elders and means the acquired ability to remember and render an entire discussion without notes or recordings. They sometimes wandered far from the original topics, compatible with a narrative approach. What I learned from our discussions was presented to the elders for their review and critique, as an indigenous adoption of a grounded theory model (Glaser & Strauss, 1967; Glaser, 1978; Glaser, 1992). The elders and I formed “think tanks” to discuss what I had learned from all of our discussions. We strived for ideas on which everyone could agree should guide the training program being creating. We called this process “quality improvement in advance”. This iterative process resulted in unanimous agreement on 12 concepts that seemed crucial to an indigenous understanding of mind and mental health. The majority of the elders represented my origins and locations – Cherokee, Northern Plains people (Ojibway, Lakota, Cree), or were from Arizona. The sample described in Table 1 represents the results of a cross-cultural group of healers who engaged in dialogue and came to same unanimous conclusions. They do not represent the views of any community or particular cultural group.

Table 1. Elders guiding this project.
Description
Background
Culture/Language
Values
65 year old male.
Bachelor’s degree from University; married to a physician; three sons; musician; healer.
Eastern Cherokee;
Learned medicine ways from his father and grandfather. Practiced traditional medicine since age 25.
55 year old male.
Retired policeman.
Lakota
Studied with Fools Crow (see Mails,1979); Received his initiation in a vision on top of Bear Butte.
66 year old female.
Master’s Degree; affirmative actions
Officer; cross-cultural consultant.
Arikara-Hidatsu;
Received her medicine training from her grandmother.
52 year old male.
20 years in the U.S. Army; retired and took up medicine ways; served in Viet Nam.
Yaqui
Received his medicine training from his grandfather.
45 year old female.
Housewife; Gradually became healer as people came to her; family tradition of healers
Mayan
Received training from her grandmother and from local Mayan healers.
46 year old male.
Employed as a printer.
Tohono-O’odham
Received his training from local healers; Also Native American Church Roadman.
45 year old female.
Health Department employee.
Penobscot
Received her training from her grandmother.
58 year old male.
Retired Worker for the Highway Department.
Cree
Received his training from his grandfather.
52 year old female.
Retired from Indian Education.
Cree
Received her training from her grandmother and other female relatives.
55 year old male.
Worked in lumber industry. Retired to do medicine full time.
Carrier
Received his training from his grandfather and from Arapahoe healers.
40 year old male.
Drug and Alcohol Counselor, using traditional medicine.
Cree
Received his training from elders in Alberta.
55 year old male.
Retired Teacher.
Cree;
Received his training from his grandfather and from an Arapahoe healer.
40 year old female.
Former Teacher; Quit to do medicine full time.
White Mountain Apache.
Received her training from her grandparents.
55 year old female.
Retired Teacher; Quit to do medicine full time.
Ojibway;
Received her training from her grandparents and other local elders.
40 year old male.
Cab driver.
Caribe.
Received his training from an uncle and relatives.
65 year old male.
Itinerant healer; travels around the U.S.
Lakota.
Received his training from relatives.
42 year old male
Physician and also traditional healer.
Haida.
Received training from his grandparents and great-grandparents, trained by local elders as well.
40 year old male
Physical therapist; artist.
Seneca.
Trained by other healing elders. No family tradition in past two generations, but rumors of medicine people before that.
48 year old male
Physical therapist.
Taino from Puerto Rico.
Trained by family members.

Key concepts of Indigenous Knowledge about Mental Well-being

1. Genuinely listening is very importance for the healing process. One elders said, “People tell you what’s wrong if you listen. They tell you how to help them. They tell you what needs to be done.” A related common theme was the importance of listening to the spirits who inform healers what to do. For some, the person’s spiritual helpers and guides speak to their spiritual helpers and guides. The underlying principle appeared to be that all healing emerged from dialogue that happens on many levels. Dialogue means “talking in order to listen”. One Cree elder spoke about listening to his dreams before someone consulted him. The dreams gave him important information about what to do to help that person. Other elders spoke about the importance of story. Their ideas were similar to those of narrative psychology (Mehl-Madrona, 2007; Charon, 2006). Several elders spoke about suffering existing within the context of a story, for all we are is story. In explanation of that, they said that all that is left when we die are the stories told about us. They believed that the self that we believe we are is just the story we tell ourselves to make sense of all the stories that have been told about us. The story lives us as we live the story. They stressed that to understand an illness it is necessary to place it within the context of the story that the person is living. To help a person, we must hear as many stories that are being or have been told about that person as is possible. They acknowledged that we can never hear them all, but we can try.
There are traveling healers especially within the Native American Church of North America, but also within other traditions as Richard Harris, the Arapahoe elder who brought the sweat lodge tradition to many Saskatchewan elders in the 1970s. These healers come to communities to lead ceremonies and stay at the homes of those who need healing and who put up the ceremony. Within this context, they spend time hearing all possible combinations of relatives to gain a perspective on all the stories being told about the person and the illness. I have observed healers talking to all possible combinations of relatives to gain a perspective on all the stories being told about the person and the illness. Some agreed that the illness itself had a story to tell, as did ancestors who had a perspective on the illness as it had come to reside within the person. They commonly consulted these ancestors during dreams or ceremony.
For example, I watched a Cree elder diagnose celiac disease in two hours. In this disease, people have antigen-antibody responses in their gut to the ingestion of gluten, a constituent of wheat and some other grains. Anxiety and depression are common. The woman who was diagnosed had been to a number of psychiatrists for her anxiety and depression, and had always received medications. The elder carefully reconstructed her story from her life before the first symptom through the beginning of the illness through its blossoming to the present time. Within an hour, he began to suspect that the woman was suffering from something she was eating. He pursued this line of questioning and discovered that her worst days were when she had deserts. He inquired about her favorite deserts. All contained dairy, wheat, and sugar. Eventually he told her to stop eating deserts. “You need to fast,” he said. “Fast four days. Then drink only good water for one day. Add another food each day. It’s probably one of those European foods,” he said. “Our bodies can’t handle them. It’s not natural for us. We eat caribou, fish, rabbit, and berries. Breads and cakes and chips and even a lot of vegetables make us sick. Our blood is different. This is a common statement I hear in the far north of Saskatchewan among the Dene people. It is a general belief used to explain why medication is undesirable. The clues were more obvious in retrospect, but the powerful listening skills of the elder had brought them out.
This woman had suffered for eight years, plagued by mental fog, anxiety, and depression. Though friends had suggested that she might have food allergies or a food-related illness, she couldn't believe that a food-related illness could cause such severe symptoms and her doctors concurred. She had gall bladder surgery in the belief that her symptoms arose from an incipient cholecystitis; though surgery did not improve her symptoms. Each successive physician blamed stress and depression for her troubles. The elder then did a ceremony to remove her illness. Immediately afterwards, words came into her mind that she had to stop eating grains. Two months later she was amazingly better on a grain free diet. When she cheated and ate chocolate cake, her symptoms returned in full force, disappearing again when she fasted and cleared the cake from her system. Each time she went off her diet, her symptoms returned, strengthening her belief that she did have celiac disease and that dietary therapy could help.
Several elders attempted to explain the importance of listening by saying that most of the professionals who they met were convinced of the superiority of their knowledge compared to that of the elders. When they encountered these attitudes, the elders acted “stupid”. To them, listening implied respect and respect mattered. Mental health workers who cannot demonstrate respect cannot work with elders. Several elders also mentioned the importance of listening to remember – the essence of an oral tradition for knowledge transfer is the importance of listening. This theme of listening and story are eloquentlydiscussed in The Lost Art of Healing (Lown, 1999). Incorporation of this first principle of indigenous knowledge into our training programs would mean abandoning our insistence that we know best in order to listen to people’s unique stories about their illnesses and lives. We would emphasize teaching students the skills of listening more than the skills of diagnosing.

2. Teach a Relational Model of the Self. None of the elders espoused a structural model of the self. They did not believe in a Platonic self existing independently of an external world that can be discovered. The elders believed that mind and self arises through a process of relational, social development. They saw each person as internalizing all the stories that had ever been told about him or her into an identity which eventually became a story about all the stories. They did not share the European concept of an “authentic” self, for they did not believe in a self except as a unifying story to guide our behavior. The elders did not separate mind and brain. They saw mind as derived from spirit which requires an earthly robe (body) to operate in the physical realm. They believed that people with damaged brains have constraints upon their sense of self, mind, and capability, but for non-impaired people, they saw the self as being a story which arose through relationships, through incorporating all the stories people tell around the person. “Self” is mediated through other people – first, the mother or other primary caretakers; second, through peers; and third, through the broader media that presents and re-presents the stories of culture.
White and Morgan (2007) believe that we construct a model (or a narrative) about ourselves based upon the results of our reflections, and then we perform that narrative in the world, consistent with the elders’ views. They agreed that the performance of a self narrative gives us corrective feedback to further refine our story that we tell ourselves about who we are. Western people tell themselves Siddhartha-like stories, in which they uncover their true self. Indigenous people tell stories about relationships and connections when asked “who are you?” Indigenous concepts of self and self-knowledge are more dependent upon relationship input and are inter-connected.
The elders’ views resembled that of Wittgenstein (1980), who said, “understanding is like knowing how to go on; it is an ability”; but “I understand”, like “I can go on”, is an utterance, a signal. For the elders, insight represented an awareness of a path to follow, a way to go on. Understanding for them was an ability to perceive. They did not believe in a mental state from which our acts spring but rather spoke of people’s behavior being determined by the stories and the contexts in which they found themselves. The elders’ concepts of self relied upon the creation of self through interaction with others. It is, as White said, "a performed Self", a co-creation arising from relationships with others and within landscapes of experience and meaning. These landscapes coalesce to form a topology which is local culture, practices, and knowledge. The concept of self is embedded in this local geography of meaning and values.

3. Teach how to help people and groups find their own solutions to problems rather than relying on externally imposed solutions. The elders were consistent in their belief that imposing an answer on someone or a family or a community would not work. People must find their own answers. They must consult their own guides and spirit helpers. They must be empowered to receive their own divine guidance. They helper or elder was only present to facilitate the conversation. The elders’ perspective was consistent with the view that increasing emphasis on the individual in communities and increasing isolation of problems from group concern leads to social disruption and consequently prohibits the formation and utilization of the necessary social relationships for the development of local solutions. It is then that communities turn to external experts to impose their distant solutions.
I told them a story about two indigenous men from my practice. Murray was chronically suicidal, frequently presenting to the emergency department to demand yet another psychiatric admission on threat of killing himself. John was chronically depressed and suicidal also, drinking frequently to excess. I had acquired both of them from being on-call. John gave up on psychiatric medications and sought healing from one of the elders. Murray did eventually kill himself, though luckily for me, after he had left me for a “better” psychiatrist (one who would give him benzodiazepines). John began to thrive outside the mental health system, continuing to work with the traditional elder, changing his life in accordance with the guidance he received in ceremony. One elder responded to these cases, saying, “It’s obvious when you doctors try to be ‘big shots’ and tell people what to do, it doesn’t work. The elder helped him find his own answers. Other people’s answers never work,” she said. “They just make you feel worse because they don’t work. You have to find your own answers.” They said that we should teach people how to help people find their own answers. We need to teach them the skills of empowerment and help them to trust their ability to self-heal.
The view of narrative philosophies is similar to that of indigenous groups and locates the self as a participant in a world in which he or she is continually acting and being acted upon. The elders discussed connectivity meaning our connections with everything around us, within us, and to that which encompasses us. They discussed accountability; that we are accountable to others to whom we relate for our actions. They emphasized the relational self over the individual self. The relational self maximizes relational quality with a desirable side effect being improvement in one’s own quality of life. Gilligan (1993) discusses “female ethics” in a similar vein, as relationship preserving over all, even if accompanied by self-sacrifice. Indigenous teaching stories are replete with examples of the individual sacrificing for the greater good of the community or of other loved ones. Coe (2006) asserts that this theme is so universal among indigenous people that it may be a required value for survival. She comments upon its absence in contemporary global modernist cultures and wonders if these cultures are destined for destruction on the basis of lack of sustainability, lack of resource preservation, concentration of wealth in the hands of a few, destruction of diversity, and extreme individualism. For narrative philosophy as well as indigenous thought as demonstrated by this group of elders (see White & Epston, 1990), the self is a story that we have internalized about others’ descriptions of how they see us. Every day that story is re-enacted as a new telling to an audience who participates in any revisions or re-authoring of the story on that day. Both narrative philosophers and indigenous people, believe that those to whom we relate each day participate in the shaping of our lives and our story about who we are.
In both views, stories told actually create the lives they describe as much as they represent them; and the control of those stories lies in the network of relationships in which the person is involved. This network includes spirits or non-physical entities and other living beings as consciousness such as rivers, mountains, and trees.
The elders agreed with Freedman and Combs (1996:35) who wrote: “Different selves come forth in different contexts, and no one self is truer than any other….While no self is 'truer' than any other, it is true that particular presentations of self are preferred by particular people within particular cultures.” The preferred Self is that Self which people can first recognize in their experiences and stories, and which they can then project into the future in the form of a story they would like to be telling, then living, themselves. Similar to White (2007), indigenous concepts of self “invite us to challenge modern notions of the self as a unitary and essential core of being that seeks expression through some singular voice that can, with 'genuine' authority, represent its own interests” (White 2007).

4. Teach that people are self-healing. Inevitably the Elders returned to the idea that nature heals herself and that we are a part of nature. They trusted this principle explicitly. They didn’t have to know how to help someone. Their job was to start a conversation between those who suffered with Nature, with spirits, and even with specific elements of nature such as rivers, land, and mountains. They were confident that healing would unfold as the information was shared. They didn’t agree with concepts of diagnosis, treatment plans, and what they considered to be external manipulation. They focused upon the mysteries inherent in 'dialogical' forms of activity in which surprises appeared and led to healing outside of what we could have predicted.
A conversation emerged with one elder about birth. I took this conversation to all the elders. All believed this was one of the most mismanaged areas of medicine. I related being attracted to birth because of its power and beauty, and the sense of journey or pilgrimage implicit in being born or giving birth. I shared my ideas that fear of birth dramatically intensifies pain and amplifies the production of hormones that can stress the baby. Then the epidural drops the blood pressure, reduces muscle tone needed to guide the baby down the birth canal, and stops or slows down labor. The hormone oxytocin is used to restart the stalled labor. Worrisome fetal heart rate patterns ensue, leading to a diagnosis of fetal distress, resulting in the cesarean. I told the elders about my work with women to help them feel empowered to give birth (see Mehl-Madrona, 2004). They were enthusiastic about the story. “All we need to know,” one said, “is already within us. It’s this modern world that tricks us to not believe in the information we receive. You have to teach people to have faith again,” she said. “You have to teach people again to see themselves as part of nature. Then they can believe in their own healing abilities. Look at strip mines. Nature even eventually covers up that mess and heals it. The same happens with people.”

5. Teach students to be selfless of intent. Time and again, the Elders emphasized the power of intent and the need for selfless intent. They saw this as intending to be healing without thought of reward or recompense. For some, it took the form of never profiting from their healing. Others were willing to profit, but only if their work succeeded. Still others were willing to profit regardless in the sense of being paid or gifted for their time, but all insisted that it was necessary to hold the highest good of the person or people being healed in the highest light above all considerations of personal reward. “Even praise can become a reward that interferes with healing,” one elder said.
I told the Elders about two doctor friends who burned out and left medicine. We looked at the growing disparity between the conventional medicine institutions pursuing profit and healing, which must often ignore personal gain. I described how my practice had transformed from 15-minute office visits to week-long intensive retreats, and how I approached the problem of people not having enough money for a visit or for what they needed. The Elders agreed that young people needed to be comfortable and make a nice salary, but they also agreed that healing was a calling and people needed to approach it from a selfless point of view. They emphasized that the healer may be the only person who believes that the sick person can get well.
This led us to the question of community. Profit-driven medicine responds to shareholders and not communities. The elders believed that healing should begin with community instead of tacking it on as an after thought. In contrast, they saw our current system appearing to work more for the insurance companies and their shareholders, managed care companies and their boards and executives, the administrators who direct the flow of dollars. The elders said that they could only work with health practitioners who were relatively pure of intent. These practitioners had to care more for other people than herself, and that we had to nurture that care and concern by taking good care of them.

6. Teach students to be passionate about their work. This point was emphasized by the Elders. They thought it helped for students to have their own illness and to have healed it first. “This is the best training,” one said. “Or at least they have to do everything that they ask others to do. They can’t stand back and make suggestions for things they have not done. That is not honest.” These elders did believe that practitioners should have to take the medications they prescribed even though that would not make sense to the biomedical practitioner. They had learned all their herbs and other therapies that way and didn’t see why it didn’t also apply equally to drugs. They believed that self-healing would generate the passion necessary to inspire quality work. They spoke of other motivations that could inspire passion – for example, illness in other family members, spirit calling, and more.
Several elders told stories about people who had come to their communities to fulfill obligations incurred by government funding of their education or because salaries were higher in indigenous communities by virtue of being rural and/or remote. “You could tell their heart wasn’t in it.” “They just went through the motions.” “They didn’t reach out to people in the community.” “They were happiest when no one came to the appointment.” In contrast, they told stories about people who were passionate and left their offices to go out into the community to encounter the people, who went looking for the people who needed help. They approved when practitioners showed genuine interest in the people and their culture and appeared to be excited about their work. Passion was seen as contagious. “You can tell when someone really likes what they do and the people they do it with.”

7. Assist students to maintain some independence from politics. The elders were insistent that healers need independence from laws, politics, and the medical establishment. They insisted that they could answer only to the Creator and to the people who came to see them and none other. The historical context for this, of course, was the Indian Act in Canada (1857), which made spiritual ceremonies and healing illegal and definitely healing illegal. Similar laws were enacted in the United States (see Waldram, 1997 and Lux, 2004).
I told the elders a story that they found entertaining and exemplary of their approach. In 1997, I gave a workshop in Pittsburgh and was invited to help start a complementary medicine program at one hospital within a health system of 29 hospitals through the University of Pittsburgh Medical Center. The Center was slated to begin with therapeutic touch provided by nurses and one part-time acupuncturist, under the direction of a Steering Committee, and under the supervision of an administrator in the Department of Surgery. My job would be to help the Center grow and expand and to develop more modalities and add more practitioners, while assuring high quality care. The job looked impossible from the beginning: do research, meet the community, give presentations, write papers, and most importantly for the institution, see patients and generate income.
We began with a different philosophy that illness could be a messenger, and that our experience of our bodies in either sickness or health, could provide us with self-understanding and meaning. I gave lectures in the community that illness was an interactive product of mind, body, and spirit; the choices we make about the way we live have a tremendous impact upon the quality of our lives and our health; and that the source of healing lies both within us and within the spiritual dimension. Almost immediately, practitioners began calling to work with us. They spanned the gamut from excellent to questionable, but many seemed to be just what we needed, and all provided resumes for us to circulate among existing staff, so that we could interview those who seemed most intriguing. Each staff member had an opportunity to comment on whom we would accept. All of our staff practitioners were independent contractors, with their own practices in the community, all interested in contributing time to our Center.
Our success drew national recognition. Unfortunately, with a new administrative appointment the decision was made to dismantle the program because the approaches were “unproven” and not “evidence-based”. This occurred despite medical staff petitioning administration that we were admirably caring for some of their most difficult patients and that we were benefiting the entire medical staff. Even a program for teaching pregnant women hypnosis to use during labor was cancelled because hypnosis was considered an unproven therapy. This experience brought home to me the perspective of the elders, that healing should be independent of politics. Since that experience, I have kept my healing work outside of institutions for the most part. I saw how conventional medicine could make indigenous healing ineffective -- by taking away the relationship, the community, the time, and treating the various therapies as interchangeable units, just like drugs.
I have seen traditional healing be sometimes spectacularly successful. It has much to offer, but, if done poorly, can be useless. Although there are many hospitals and health care systems where traditional healing is welcomed, it also true that when traditional healing is placed within a conventional medicine system, freedom to practice can be lost, providers can be limited in the number of visits allowed with each patient, how long they can spend with patients, what modalities they can use for any patient, or being allowed to work only with specific diagnoses. The elders had knowing nods in hearing this story. “Of course that would happen,” one said. “It’s all about greed.”

8. Teach students the importance of faith, hope, and the power of the activated mind. The elders agreed that hope is only necessary for those of us who struggle in the throws of uncertainty. Like patients with life-threatening illnesses, or those with chronic illness for whom medicine has no answers, or the depressed, the homeless, and the disenfranchised, when we can't be certain an answer or a cure is forthcoming. Hope springs from a different source than knowledge. The spring nourishing the waters of hope requires no science to make it flow. I told several of the elders a story I told a patients who was terrified of dying, but deeply religious, having studied Buddhism for many years. I shared a guided meditation I did with a man, framing our shared concepts in Buddhist terms. The elders agreed that this was a good example of how they thought.

Being in the present moment does not mean your body will not die. Your body may die, and you may not even notice. You are not this body. You are the ocean and not the wave, rolling onto the shore.

While you are suffering through this chemotherapy, I want you to remember that you are not the body who suffers. The body is like a wave in the ocean. Your pain is also like a wave in the ocean. It peaks, crests, and then rushes toward the shore. When it reaches the shore, it is gone. The nausea, too, will pass. You may live another fifty years, but eventually your body will pass. You could remember that you are not this body. This body is merely the vehicle through which you negotiate this physical reality of this time and space. You will not disappear with this body.

The past of this body is full of pain. The past of this body is caught in the causes and conditions that created cancer. Some of these conditions may continue and may be sustaining and feeding your cancer and ill-being in general.

You are feeling uncomfortable for many good reasons. The current body conditions are not favorable. You feel you are on the right course. You need this medicine [the chemotherapy]. How can your body accommodate to this medicine.

It is like being cold, being out in the cold. We cannot deny that we feel cold when we are cold. We cannot deny feeling nauseated when we feel this. We cannot deny pain when it is present. But consciousness is like a searchlight. What is illuminated can eclipse all else. What is caught in shadow does not go away. Rather it is no longer prominent. Consciousness can rotate again and catch the unpleasant in its light. Or we can linger on other matters.

Let the searchlight of consciousness begin to rotate. Like a lighthouse on Martha's Vineyard. Your body is nauseated, yes. But so what. There are other experiences to enlighten. There are other possibilities for this present moment. Your body will take care of itself. The nausea is not dangerous. The discomfort you are feeling is not an alarm. You know what is happening. You are having chemotherapy. There are other places to explore, other states of mind to visit.

9. Teach students to prefer empowerment over treatment. I told the Elders about a man with nine angioplasties in three years, who was never told that these procedures could help relieve his pain and improve his quality of life, but would not necessarily, prolong his life. He was never told about the Dean Ornish program, the importance of exercise, or the Mediterranean diet, all of which have been shown in rigorous studies to prolong life (Koertge, 2003). I used his story to wonder about the difference between treating people and empowering them to think for themselves. This patient was used to finding the "best" doctors, and then doing whatever they told him to do. But how does one define best? In his city, best often meant, most aggressive, willing to do the most procedures, or willing to act more quickly than anyone else. Yet good medicine sometimes means doing nothing or motivating patients to do for themselves. It sometimes means giving patients the information to make their own decisions, and supporting them to do so.
The Elders were in agreement. While not all used to the term “empowerment,” the concept was quite familiar. “We cannot fix anyone,” they said. “Only the Creator has that power. And we cannot make anyone do what spirit tells them to do. We can only tell them stories to uplift and inspire them and to make them believe in their own power to act and in the power of spirits to respond to what they do.” Another said, “If you hear enough good stories of other people getting well, you begin to believe that you can, too.” A third said, “When know when someone is really on the road to getting well, because suddenly there’s that spark of knowing that what they do really matters and that every little step they take toward getting well makes a difference.”

10. Teach students the importance of community. In our discussions, a story arose that I shared with the elders. No matter how hard I struggled with Joseph, nothing changed. His chronic fatigue became more chronic. His fatigue deepened. His joints hurt. Despite what I thought were my best efforts, he continued to decline. At my wit's end, I called one of my elder advisors who suggested that I asked Joseph to bring everyone he knew to our next appointment. We went around the circle, with each person holding the Talking Stick being able to talk to their heart's content without interruption, all addressing the question of why Joseph wasn't getting better. By the end of that 2-hour session, they had given me a treatment plan and told me exactly how to proceed with Joseph. I wondered why I hadn't done this much earlier. Armed with this advice, my work with Joseph changed radically, as did he. The group he brought continued to meet monthly to struggle with the question of how each of them individually and the group collectively could help Joe toward recovery. I realized that any attempt on my part to claim effectiveness was shortsighted. We all did it together. The elders said that was similar to what happens in a healing lodge. Some also used talking circles. They agreed that the community has much more power to heal than the individual does. Another remembered one of her elders her said that the old ceremonies weren’t as powerful anymore because the community wasn’t as strong as it used to be.
I told another story about Gayle. She was depressed, not improving despite my most inspired efforts. I imagined that I was doing the best guided imageries, the best storytelling, the best cognitive behavior therapy, but was still seeing no change. After further discussion with my elder advisor, I made a similar request of Gayle. Twenty-five people arrived, only ten less than the number Joseph brought. Gayle's community was much stronger and more focused. The community decided without any intervention on my part that Gayle needed to sell her mother's house now that her mother was dead and get on with her life. She needed a car, and she needed to go "drive about." The group arrived with that idea from the Australian aboriginal concept of "walk about." They said no one walks about in America; of course, they drive.
The group pushed, prodded, and even did things for Gayle to help her follow the commitments she made in that first session. Further meetings followed her progress. By the summer she was in her car, camping in Arizona. Her depression was rapidly clearing, with minimal help from me. After two years of drive about, she settled in a small Colorado, mountain town, where she happily continues to reside. Luckily in both situations, we had a large waiting room and could meet after hours. These patients taught me to request a meeting of a person's entire community when that person isn't improving despite our best efforts. This practice has saved many a fruitless session. The elders told me that community contains the wisdom which the individual lacks. Collective minds offer more wisdom than individual minds. This is why, the Elders said, ceremony is done with more than one person. Everyone’s prayers and intent matter. The elders agreed that these two stories illustrated their principle of the importance of community.

11. Teach students that only Creator can give prognoses. Since medical school I have been collecting stories of survivors from illness who worked with the elders who were my teachers for this paper. These were people who beat the odds (Mehl-Madrona, 2008). In discussing these stories with the elders, we realized that the vast majority of those survivors learned that there were many positive messages inherent in their illness discovered on the road to recovery. One of them was gratitude, or how important it is to feel fortunate. One element of being fortunate is to rediscover spirituality in our lives; not only the belief in God, but the love and forgiveness that is necessary in our hearts and the welcoming of helpers and friends along the way. The elders said we must do this while learning how to overcome the disease with good nutritional habits, exercise, faith in the treatments we choose, stress management, hope, love, and support from relatives and friends. We learn to see each day's progress as leading toward the capability of being able to take charge in our own wellness plan.
They said all faiths have similar goals in mind...the importance of knowing what life is, the necessity of knowing the time we have here on this planet and maybe even more important, how love grew between those that were thrown into this era of pain. Within this context, they said, only Creator knows what the final outcome will be. It is wrong to tell people how long they will live. We cannot know that. Powerful transformations and healings do happen and we should not try to convince people of the inevitability of their imminent death. Nor should we try to white wash the severity of their illness and how serious it is. No matter what, healing is always possible and Creator trumps all of our scientific predictions, they said.

12. Teach students that all healing is ultimately spiritual healing.

The elders agreed that all healing was fundamentally spiritual healing. Without the spirit’s permission, no healing could occur. For them, spiritual healing represented the “deepest” healing with others lagging behind. This occurs in sharp contrast with most hospitals recognizing elders as spiritual advisors, but not as healers. Spiritual healing was seen as the most fundamental form of healing, the other methods riding on top of it. All agreed with the idea that the individual’s spirit had to want to get well before any intervention – even surgery – could work. The spirits willingness to be well was a necessary ingredient. One elder told a story about a man who came for healing of his colon cancer. This elder received a very strong message from his spirit guides that this man’s spirit wanted to leave this world. Nevertheless, the elder did his best to help. The cancer surgery was surprisingly a complete success. The several cancers that had been found had coalesced into one more or less contiguous and very removable tumor. The surgeons were thrilled and predicted complete recovery. On the way out of the hospital, as he was walking out the front door of the hospital, the man dropped dead from a massive heart attack. The man’s spirit has its wish.

Sidebar: Discussions with traditional healing elders from the U.S. and Canada raised 12 common points that were unanimously accepted as guideposts for training mental health workers who wish to work with aboriginal people. These guideposts are:

1. Teach students the importance of listening.
2. Teach Self is relational and identity is narrative.
3. Solutions must be internally derived.
4. People are spontaneously self-healing.
5. The healer should be selfless of intent.
6. Healers need to be passionate about their work.
7. Healers have to maintain some independence from political structures.
8. The importance of faith, hope, and the power of the activated mind.
9. Empowerment is different from treatment.
10. The importance of community
11. Only Creator can give prognosis.
12. All healing is ultimately spiritual healing.

Discussion

Perhaps we should follow the elders’ advice and adopt some of these considerations into our thinking about how to teach. Effective psychotherapists are those who are enthusiastic about what they do (Stratton, 2007). The client must also believe in the therapist. At least, with regard to indigenous populations, there are concerns that make a therapist seem caring and believable, that are not always addressed in conventional training. As the elders say, perhaps they should be. Psychotherapy research also indicates that patients, not therapist interventions, result in therapeutic change (Bohart and Tallman, 1999). The relationship is more important but patients do the work, even with poor therapists. Perhaps these items stressed by the elders would help even poor therapists be more effective or become better therapists.
A literature does exist on what students need to learn to work effectively in indigenous communities. Vella (1994), for example, recognized the need for students to learn how to listen and how to engage in genuine dialogue from positions of social equity. Thrup (1989) wrote about the need to teach students how to recognize clues that could lead to the development of empowering solutions to problems emerging from the dialogue of all those who were affected by the problems. Barnes (2000) wrote that we need to recognize problems as belonging to communities instead of individuals and to address the needs and resources of communities instead of stigmatizing individuals as defective or inferior. Krippner and Welch (1992) emphasized the need to teach acceptance of the spiritual dimension and to expect help from this arena, while Csordas (1983) wrote about the need to teach faith in nature and in the spontaneity of healing. Kakar (1982) commented on the dialectic between being able to expect a decent standard of living and needing to learn how to manifest selflessness of intent and how to hold another’s highest good as our focus. Krippner et al. (2004) added that we need to allow and encourage our students to be passionate about their work, to reject clinical detachment and obstructive professionalism in favor of a warm humanity. Myers et al. (2000) wrote that we need to help our students cultivate a sense of humor that is contagious. Peeling and Napoleon (2006) wrote that we must encourage students to stay somewhat independent from the political intrigues of modern health care, so that they can do their work.
Frequently we hear that we should teach students to cultivate faith and hope and to believe in the power of mind, especially of minds in community (American Public Media, 2006). Mihesuah (2003) wrote that we should teach students to empower instead of fixing or treating (Mihesuah, 2003). What all this suggests is that appropriate training for working with indigenous people is different from currently offered mainstream training programs in the mental health fields, which are often concerned with teaching students how to be expert professionals who apply solutions to fix or treat problems, expecting their patients to comply with expert advice. Spirituality is rarely discussed. Clinical detachment and professionalism is emphasized. Humor is rarely encouraged. From reflecting upon this list I concluded that our trainees need to be more humble. They need to work hard to develop their abilities to listen and to grasp the story that the person is living. The must appreciate the power of community and ground their activities in the idea of a relational self and a narrative identity. They should foster dialogue and trust in the self-healing nature of systems. We should fuel their passions, protect them from political structures, and insist that they consider the power of faith, hope, and mind. Their therapies should empower more than treat and they should refrain from labeling and predicting the future based upon labels as much as possible. I was struck by the strong parallels between the narrative movement and aboriginal thought, and suspect that this area of psychology may be most simpatico with aboriginal people and their needs.
If we believe these elders, perhaps mental health training should be modified. Perhaps we should emphasize learning how to listen without theory and teach theory-less interviewing and dialogical skills before we teach theory. We should increase our exposure of students to non-European or mainstream world views, to how other cultures see the world differently from their own, not as an object of study, but as a potentially equal point of view to the standard perspective (logical positivism) of conventional social science, psychology, and medicine. We should use community mentors, such as elders, from communities in which our students will work. They should be equal collaborators with adjunct faculty appointments. We should include more training on methods of work that involve communities and larger groups than just the individual. We should include more training on intuition, spirituality, and more exploration of our own motives, intent, and values.
While students must learn what is generally accepted by mainstream practitioners and licensing boards and they must be competent in the standard practices of their field, perhaps more humility is indicated in our convictions about “the truth”. Indigenous world views could be as valid as those of contemporary social and medical science. They may be more valid for those people who hold them. Including narrative perspectives could allow the student to be more flexible in moving through a broad range of world views and more able to work with world views that are not his or her own.
In the training program that resulted from this inquiry (http://groups.google.com/group/crossculturaltraining), we chose to include a community mentor (elder) throughout the training, to ask the student to begin learning the language of the culture in which he or she will work and to reflect upon the relationship of language and consciousness. We will teach classes on generating genuine cross-cultural dialogue, indigenous models of mind and mental health, traditional cultural healing, and indigenous-friendly therapies, as well as the more conventional courses required for licensure. Our outcome measure will be retention in ethnic, rural, and remote communities. Our graduates should have more staying power through gaining a genuine respect for the culture in which they will work and engaging members of that culture in mutually satisfactory ways.

Closing Story. In keeping with indigenous principles and methods, I wish to close, as suggested by one of the elders, with a story – this one from the Pima people of central Arizona (Mehl-Madrona, 1998). This was the story one of the elders first told me when I began our discussions. He simultaneously viewed contemporary psychotherapy as a foolish coyote who falls from the sky and indigenous healing for mind and mental health as a resilient coyote who comes back from the dead. Coyote is one of those traditions from the indigenous world, and he has much to say about mental health, though he often seems to have none. Coyote stirs us up and makes us laugh (first at him, later at ourselves when we realize we are acting just like him). Coyote keeps challenging all our assumptions, annoying and irritating us. He doesn’t accept anything on face value or “because authority says so.” When we think we have killed him off, we realize we miss him. The somber silence is overwhelming. We need levity. We ask for Coyote to come back, and discover that he has reappeared everywhere. This is indigenous knowledge. It can’t be suppressed. Whenever it is “killed”, like the Hydra, it reappears in greater quantity than before. In keeping with an indigenous approach to presenting this material, I tell the story this elder told me as his conclusion to our discussion. At the end, he told me that Coyote was the only true psychotherapist. (For more on coyote, see Mehl-Madrona, 2008b):

One evening Coyote came to listen to Buzzard tell a story about the time he flew to the Land Above. Buzzard told about flying up, flying way up into the clouds, higher than he had ever flow before, so high that he himself was terrified, until he came to an opening in the sky that looked like the mouth of a cave. Coyote was so excited, he couldn't help but interrupt. "Tell more," he would say. "Tell it faster, Brother Buzzard."
Buzzard snuck through the entrance and discovered a whole other world. There were people singing and dancing. There were animals and plants. He feared the hole in the sky would close up and he wouldn't be able to get back to his own kind. Coyote interrupted again, calling out in a most irritating voice, "Can you get back, Buzzard? You've got to take me there. You've got to show me this place." After the story ended, Coyote slinked up to Buzzard and begged to go with him to the Land Above. Buzzard didn't really want to take Coyote, but Coyote was so insistent that Buzzard could not say no.
Buzzard knew that coyotes love games of chance. He demanded that Coyote not play any of his games of chance with the Sky People. Coyote, on the other hand, figured that he would really clean up with the Sky People. They would not be familiar with his particular games, and he would have the expert's advantage. Buzzard and Coyote worked out a compromise on the gaming, and Buzzard prayed to the Wind to lift them up and carry them into the Land Above. Coyote clung tightly to Buzzard's back, shivering with fear at the great heights and trying not to look down. After a while, he could even open his shivering eyes.
When they arrived and Coyote climbed off his back, Buzzard admonished him to be back at the cave entrance by sunset. Buzzard needed the last bit of the sun's rays to carry them safely down. Coyote wasn't listening. He was preoccupied with what he was going to win from the Sky People. Coyote had a wonderful time. He tried to trick all the people in the sky with his games, but he had finally met his match. The Sky People had their own games of chance, which fascinated him so that he didn't notice time passing--until suddenly it was dark. He had missed the rendezvous! He was stuck in the sky.
Coyote ran lickety-split to the opening to the cave, but Buzzard had already left. He saw Buzzard's tracks leading to the opening and ending just at the point at which Buzzard would have jumped into the blue. Coyote looked down and couldn't even see the ground because it was so far down. Coyote did not want to live in the Sky. In his frenzy, he figured that his only course was to jump. Terrified as he was, he backed up and ran toward the opening. Three times he ran and three times he stopped short, panting with fear. On the fourth try he jumped. Two days later a big bag of bones hit the ground with a thud. It was Coyote finally landing on the ground.
Coyote's burial was prepared and his bones were placed on the hillside in the proper way in a sacred place. When the prayers and songs ended, the animals returned to their homes, sadly humming Coyote's last song. Complaining about Coyote's tricks had been fashionable, but no one wanted to be rid of that trickster. Someone has to challenge the rules that have no reason or meaning.
Little did the animals know that night would see the Great Spirit answer their prayers. Spirit took every piece of bone and spread it all over the earth. Every fragment of bone became a coyote. When the animals awoke in the morning, every distant hill had a little coyote howling at the moon, imploring it to stay awake. Next evening, every distant hill had a little coyote howling at the moon to come out and play....

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[1] Exceptions occur in highly Christianized communities in which the elders use Christian methods and principles of healing, sometimes more or less meshed with their former cultural practices. This is common in the North of Saskatchewan, where the first author spends one week per month.

Contemporary Psychiatry and Diagnostic Labeling

2008-04-12T15:12:00.002-07:00

Here is a discussion that Barbara and I have been having on the Coyote Medicine discussion group. I liked it and thought it would fit nicely on this blog so others could potentially read it and join in.

She's responding to an article posted by Kirmaier et al, regarding Inuit Models of Mind and Mental Health which is available at http://groups.google.com/group/coyotemedicine.

I read this article when I was thinking, why not dissolve the idea of mental illness and go back to what seems to get pathologized or at least what it is in a person that makes other people think something needs to be done.

So I really responded to the different ways of describing an illness, the idea that illness is seen as "accidental, due to the breaking of taboos, soul loss and/or the action or intrusion of evil spirits" (p. 16) and the specific nature of the illnesses that's described in the next few pages. So, there is a sense of suffering, and there seem to be various elements to it - the person does or doesn't have awareness, the suffering is permanent or brief and transitional, the suffering mind has some thoughts or none at all (seeming). Treatments within the community ranged from none (e.g. acceptance of epilepsy that it was a moment of spirit bonding) to support and prayer (for sadness) to beating a person, if they were afflicted with "Quajimaillituq: "he does foolish things and does not know what he does" (a term also used for rabid dogs during the violent phase of their illness). In this state, individuals were hyperactive or agitated, with incoherent or disjointed speech, loose associations, paranoid suspicions and compulsive rituals. They avoided sleep, were aggressive, blasphemous and might harm self and others."

I notice that both "sad, troubled, quiet" and epilepsy are considered to have possibilities of some kind of transition to the divine in them (the former mostly for men).

Mostly, I wonder if we can bring something into western discussions of madness (the preferred term these days among my friends who disapprove of psychiatric categorization) by considering the way we pathologize states of consciousness by the way we ascribe meaning to them - e.g., we reduce the meaning of most states of consciousness to a kind of binary of, 'trouble for the rest of us' or 'not trouble for the rest of us' and then medicate accordingly. A friend of mine who was diagnosed a long time ago and went off medications in the 80s is now a professor (he teaches a 'history of madness' course - an initiative that is spreading to a few universities) bemoans the intolerance for someone who just needs to withdraw for a while,for example, and suggests also that there be a mad voice at every table to provide the 'mad' perspective (another old anti-psychiatry activist I know is working to revise our conception of what hearing voices means). People I know who suffer want the relief of medications, regardless of what they suppress or toxify, and it seems arrogant of me to expect that they 'should' undergo a personal journey that could be really hard because I believe that Gaia would like it better and could benefit from the multiplicity of voices (maybe suppression of the 'mad' thoughts detracts from the beauty of the collective consciousness - but I don't want to sentimentalize mental illness). I'm making a documentary essay film to puzzle through all this.

Barbara

Also I was struck by the notion of treatment specific to the meaning of the illness. Is it fair to say we treat the social condition of 'annoying to us' rather than find healing ideas that might actually work for the troubling condition? E.G. 'needs to eat the food of home' works as it treats the illness, but is way to simple for the likes of us, I suspect. Lewis, I think you once said that to properly heal you need to expect that you will be able to heal, and that some medicine doesn't seem to carry that expectation. I think this article speaks to that idea. Barbara And I know the DSM officially requires distress to the sufferer, but I can't help feeling that the sufferer might feel a lot less distress if we were more accommodating.

Lewis MehlMadrona

Dear Barbara.
I agree. It appears to me that all cultures define pain and suffering though not all define mind or mental health or even health at all. I suspect we should revert to the position that healers exist to help with the reduction of pain and suffering and that all cultures have individuals who perform those functions. Do you know any cultures that do not have such roles for people to assume.

When these roles are institutionalized, the problems begin. My sense is that the healer role has been corrupted by contemporary global modernist cultures into a different role than indigenous societies intended. The current role is more expert-salesperosn than healer. I turn to Foucault for illumination on this. His perspective that current events can best be understand from the history of how they came about -- a sort of archaeology as it were, makes sense to me. Foucault talks about knowledge production enterprises which encompasses Medicine. Medicine produces products and experts, both of which need consumers. Foucault's perspective that the labeling and isolation of madness arose with th petite bourgeoisie because a consciousness of the need for appearances arose and wherever you go, there are people who annoy and irritate others. These people are dealt with when the annoyance and irritation becomes sufficiently great, as in the Inuit paper when they beat someone who is agitated (having the desired effect of the person calming down). Before pharmaceuticals, exclusion was sufficient, a kind of quarantine approach to the annoying and the irritating. Then a brainstorm occurred. A profession of experts could be created to ride herd over these individuals -- shepherds if you will. These shepherds came to be called psychiatrists eventually. Naturally these shepherds had to do what they could to consolidate their position as experts and to increase their status in the eyes of other experts and other knowledge systems. They had to dominate the various available knowledge systems. So this is what I see today -- psychiatrists have found ways to dominate all other theories and have relied upon what they uniquely (at least in the past) could do, which is prescribe drugs. It works for the pharmaceutical industry which is a self-fulfilling prophecy of promising drugs to ease all pain and suffering and using its power and money to infect the public with the "better living through chemistry" story. So people demand "better living through chemistry" and now the "expert-salespeople" try to accomodate them.

I see that what some of us are trying to do is to hold onto another vision of healing -- an indigenous vision that re-posits the healer as a role separate from the knowledge-expert system of psychiatry and independent of the pharmaceutical industry, which psychiatry is not. We must, I believe, keep separate the conversation about biology and mind and brain from the expert-knowledge system that is called psychiatry. For me, we all have brains and brains are shaped and maintained in their present configurations by environment, past and present. We can believe in brain without believing that drugs are the only ways to change brains. Social interaction, I believe, changes brains more powerfully than chemistry.

My conclusion is that we are minority voices, stories that need to be told and maintained for the good of society, because diversity is important. We need biodiversity to enhance survival potential. I suspect that the story that modern global psychiatry tells is unsustainable. The costs are too high for the planet to maintain. The social interactionist story, as in the WHO studies of schizophrenia, or the psychosis projects of Altoonen, Burke, Laing, Mosher, Perry, etc. are more sustainable. Humans helping humans is less profitable overall but more affordable in the long term. People need meaning and jobs more than pharmaceutical company stockholders need dividends and more than psychiatry experts need status and power. However, the economy will have to get much worse before than becomes a trend. Perhaps the third world countries are lucky in this regard.

That's why I started these discussion groups and my other collaborative online projects (see My Projects at http://mehlmadrona.mysite.com). Because we minority voices (post-modern, semi-urban, neo-shamanic healers) need each other to keep a little toe hold in the world. We are as annoying and irrtating to the mainstream as are "the mad" to the petite bourgeoisie. So we must keep telling each other our stories and hold each others hands in an unbroken circle and keep doing our projects and demonstrating that our stories also work (though I am very unimpressed with the pharmacological story for suffering in that it rarely works without creating as much suffering in the form of side effects as it purports to relieve; and I admit exceptions, like a couple of people I see who were very paranoid and were helped by risperidone and quetiapine, respectively, to suffer less. Interestingly, they had no side effects. I suspect that enveloping them in a loving human community, the ultimate holding environment, would have worked better. But it just wasn't available. And this is the most interesting aspect to me about the knowledge-expert system of psychiatry, that it aims to become unemotional. That it promotes a kind of social aim to make love and community and emotion bad or disturbing. I suspect this is so because people consume more if they are isolated and unfeeling and disconnected. I suspect that it's in the service of global capitalism. Certainly, the modern "psychotherapies" lack soul -- like CBT or IPT, and are proud of their lack of soul or warmth or humor or love or connectedness (though I know people who do CBT who demonstrate all these qualities, so my argument is about the "official" presentation of the technique rather than what people actually do, since I actually use all the CBT "techniques" and have for years without calling them CBT.). Enough for now.

This has been the start of a good discussion and I hope others join us.

Lewis

Contemporary Psychiatry and Diagnostic Labels

2008-04-12T14:55:00.004-07:00

Check out this conversation that Barbara and I have been having on the Coyote Medicine discussion group.

Barbara starts the conversation regarding an article by Kirmaier et al on Inuit Concepts of Mind and Mental Health (it's posted at http://groups

I read this article when I was thinking, why not dissolve the idea of mental illness and go back to what seems to get pathologized or at least what it is in a person that makes other people think something needs to be done.

So I really responded to the different ways of describing an illness, the idea that illness is seen as "accidental, due to the breaking of taboos, soul loss and/or the action or intrusion of evil spirits" (p. 16) and the specific nature of the illnesses that's described in the next few pages.
So, there is a sense of suffering, and there seem to be various elements to it - the person does or doesn't have awareness, the suffering is permanent or brief and transitional, the suffering mind has some thoughts or none at all (seeming). Treatments within the community ranged from none (e.g. acceptance of epilepsy that it was a moment of spirit bonding) to support and prayer (for sadness) to beating a person, if they were afflicted with "Quajimaillituq: "he does foolish things and does not know what he does" (a term also used for rabid dogs during the violent phase of their illness). In this state, individuals were hyperactive or agitated, with incoherent or disjointed speech, loose associations, paranoid suspicions and compulsive rituals. They avoided sleep, were aggressive, blasphemous and might harm self and others."

I notice that both "sad, troubled, quiet" and epilepsy are considered to have possibilities of some kind of transition to the divine in them (the former mostly for men).

Mostly, I wonder if we can bring something into western discussions of madness (the preferred term these days among my friends who disapprove of psychiatric categorization) by considering the way we pathologize states of consciousness by the way we ascribe meaning to them - e.g., we reduce the meaning of most states of consciousness to a kind of binary of, 'trouble for the rest of us' or 'not trouble for the rest of us' and then medicate accordingly. A friend of mine who was diagnosed a long time ago and went off medications in the 80s is now a professor (he teaches a 'history of madness' course - an initiative that is spreading to a few universities) bemoans the intolerance for someone who just needs to withdraw for a while,for example, and suggests also that there be a mad voice at every table to provide the 'mad' perspective (another old anti-psychiatry activist I know is working to revise our conception of what hearing voices means).
People I know who suffer want the relief of medications, regardless of what they suppress or toxify, and it seems arrogant of me to expect that they 'should' undergo a personal journey that could be really hard because I believe that Gaia would like it better and could benefit from the multiplicity of voices (maybe suppression of the 'mad' thoughts detracts from the beauty of the collective consciousness - but I don't want to sentimentalize mental illness).
I'm making a documentary essay film to puzzle through all this.

Barbara

Also I was struck by the notion of treatment specific to the meaning of the illness. Is it fair to say we treat the social condition of 'annoying to us' rather than find healing ideas that might actually work for the troubling condition? E.G. 'needs to eat the food of home' works as it treats the illness, but is way to simple for the likes of us, I suspect. Lewis, I think you once said that to properly heal you need to expect that you will be able to heal, and that some medicine doesn't seem to carry that expectation. I think this article speaks to that idea.

Barbara

And I know the DSM officially requires distress to the sufferer, but I can't help feeling that the sufferer might feel a lot less distress if we were more accommodating.

Dear Barbara.

I agree. It appears to me that all cultures define pain and suffering though not all define mind or mental health or even health at all. I suspect we should revert to the position that healers exist to help with the reduction of pain and suffering and that all cultures have individuals who perform those functions. Do you know any cultures that do not have such roles for people to assume.

When these roles are institutionalized, the problems begin. My sense is that the healer role has been corrupted by contemporary global modernist cultures into a different role than indigenous societies intended. The current role is more expert-salesperosn than healer. I turn to Foucault for illumination on this. His perspective that current events can best be understand from the history of how they came about -- a sort of archaeology as it were, makes sense to me. Foucault talks about knowledge production enterprises which encompasses Medicine. Medicine produces products and experts, both of which need consumers. Foucault's perspective that the labeling and isolation of madness arose with th petite bourgeoisie because a consciousness of the need for appearances arose and wherever you go, there are people who annoy and irritate others. These people are dealt with when the annoyance and irritation becomes sufficiently great, as in the Inuit paper when they beat someone who is agitated (having the desired effect of the person calming down). Before pharmaceuticals, exclusion was sufficient, a kind of quarantine approach to the annoying and the irritating. Then a brainstorm occurred. A profession of experts could be created to ride herd over these individuals -- shepherds if you will. These shepherds came to be called psychiatrists eventually. Naturally these shepherds had to do what they could to consolidate their position as experts and to increase their status in the eyes of other experts and other knowledge systems. They had to dominate the various available knowledge systems. So this is what I see today -- psychiatrists have found ways to dominate all other theories and have relied upon what they uniquely (at least in the past) could do, which is prescribe drugs. It works for the pharmaceutical industry which is a self-fulfilling prophecy of promising drugs to ease all pain and suffering and using its power and money to infect the public with the "better living through chemistry" story. So people demand "better living through chemistry" and now the "expert-salespeople" try to accomodate them.

I see that what some of us are trying to do is to hold onto another vision of healing -- an indigenous vision that re-posits the healer as a role separate from the knowledge-expert system of psychiatry and independent of the pharmaceutical industry, which psychiatry is not.
We must, I believe, keep separate the conversation about biology and mind and brain from the expert-knowledge system that is called psychiatry. For me, we all have brains and brains are shaped and maintained in their present configurations by environment, past and present. We can believe in brain without believing that drugs are the only ways to change brains. Social interaction, I believe, changes brains more powerfully than chemistry.

My conclusion is that we are minority voices, stories that need to be told and maintained for the good of society, because diversity is important. We need biodiversity to enhance survival potential. I suspect that the story that modern global psychiatry tells is unsustainable. The costs are too high for the planet to maintain. The social interactionist story, as in the WHO studies of schizophrenia, or the psychosis projects of Altoonen, Burke, Laing, Mosher, Perry, etc. are more sustainable. Humans helping humans is less profitable overall but more affordable in the long term. People need meaning and jobs more than pharmaceutical company stockholders need dividends and more than psychiatry experts need status and power. However, the economy will have to get much worse before than becomes a trend. Perhaps the third world countries are lucky in this regard.

That's why I started these discussion groups and my other collaborative online projects (see My Projects at http://mehlmadrona.mysite.com). Because we minority voices (post-modern, semi-urban, neo-shamanic healers) need each other to keep a little toe hold in the world. We are as annoying and irrtating to the mainstream as are "the mad" to the petite bourgeoisie. So we must keep telling each other our stories and hold each others hands in an unbroken circle and keep doing our projects and demonstrating that our stories also work (though I am very unimpressed with the pharmacological story for suffering in that it rarely works without creating as much suffering in the form of side effects as it purports to relieve; and I admit exceptions, like a couple of people I see who were very paranoid and were helped by risperidone and quetiapine, respectively, to suffer less. Interestingly, they had no side effects. I suspect that enveloping them in a loving human community, the ultimate holding environment, would have worked better. But it just wasn't available. And this is the most interesting aspect to me about the knowledge-expert system of psychiatry, that it aims to become unemotional. That it promotes a kind of social aim to make love and community and emotion bad or disturbing. I suspect this is so because people consume more if they are isolated and unfeeling and disconnected. I suspect that it's in the service of global capitalism. Certainly, the modern "psychotherapies" lack soul -- like CBT or IPT, and are proud of their lack of soul or warmth or humor or love or connectedness (though I know people who do CBT who demonstrate all these qualities, so my argument is about the "official" presentation of the technique rather than what people actually do, since I actually use all the CBT "techniques" and have for years without calling them CBT.).
Enough for now.

This has been the start of a good discussion and I hope others join us.

Lewis

More Bipolar, Part 2

2008-03-26T20:17:00.000-07:00

The recovery of unmedicated schizophrenics did not prove that schizophrenia is a psychological and not a biological illness. It proved that biology responds intimately and immediately to one’s surroundings and to the treatment that can be provided in that environment. The facilitation of labor with behavioral methods and the prevention of labor complications with hypnosis similarly showed that psychology and biology are two sides of the same river.

Native American medicine people never lost this “primitive” understanding so common in traditional and pre-literate cultures, that mind, body, spirit, and community are one, that are modern boundaries between self and others, self and nature, self and spirit are artificial constructions of a restricted materialistic vision.

Some scientists are now discovering these truths of our ancestors.[1] Dr. Elisabeth Targ, clinical director of psychosocial oncology research at California Pacific Medical Center in San Francisco, conducted a study of 20, randomly selected, severely ill, AIDS patients. Half were prayed for by traditional folk healers; half were not. None were told which group they were assigned to. The results were positive for the prayed-for group, even with that small sample size.

Dr. Jeffrey Levin of Eastern Virginia Medical School and Dr. David Larson, of the National Institute for Healthcare Research, have found over 200 studies in the existing medical literature proving the value of spiritual healing. These include a 1995 study from Dartmouth University showing that one of the best predictors of survival among open-heart surgery patients was the degree to which they said they drew comfort and strength from religious faith. Those who did not had three times the death rate of those who did.

Churchgoers had lower blood pressures than non-churchgoers, men and women who regularly attended church had half the risk of dying of coronary artery disease as non-churchgoers, elderly who attended church or workshipped at home were less depressed and physically healthier than non-worshipping counterparts, elderly hip fracture patients who regarded God as a source of strength and comfort and who attended religious services were able to walk farther on hospital discharge and had less depression than those who did not, to name a few of the findings. Each study took into account other contributing factors that could have offered alternative explanations. The benefits of religion held up even for cigarette smokers.
[1] Wallis C. Time Magazine, June 24, 1996, pp. 59-62.

Bipolar Disorder -- more work in process

2008-03-18T08:59:00.000-07:00

The green grass hills seemed to stretch forever, limited only by the bright blue horizon. It was not hard to imagine those hills covered with bison while eagles circled overhead. Through the dissolving morning mist, we could still an eagle gliding on the heat currents above us, though no bison would appear. We had come to Nick Standing Bear’s spread for sun dance. One year ago I had brought Anna to see Nick. She had never left. I looked forward to seeing her again, having kept in touch by letter, and having seen her twice during the year at other ceremonies.

Anna had come to me in Pittsburgh. She was part black, part Cherokee, a product of slavery times in the Deep South. Anna had been hospitalized every two years for as long as she could remember. She had been tried on every medication known to psychiatry. All gave her side effects, some life-threatening.

Anna had what we call bipolar disorder. This used to be called manic-depression. The term implies extreme ranges of mood, from elation to the deepest of depression. Unfortunately for them, bipolar patients spend 85% of their time being depressed. And, unfortunately, when they became elated, they can become sufficiently bizarre to become hospitalized or jailed. The elation is not without its associated consequences. Anna became paranoid and hypervigilant, ever searching for threat. She felt pressured to talk, but would reveal too much, making everyone uncomfortable around her. When her mania became extreme, she would become psychotic, misinterpreting the world around her and its intentions so severely that she would end up in restraints in a psychiatric hospital. She bitterly described her trauma of being tied up and secluded. The mental health care system was brutal to her. She came to me because she wanted an alternative. She felt herself getting paranoid, she knew something had to be done. She didn’t want more medication. Her past doctors had been encouraging a drug called Clozaril,

Anna illustrates an important narrative principle also spoken by indigenous knowledge keepers – that knowledge is the outcome of interactions and relationships between the inquirers and participants. Here is the radical difference in views – that there is no a priori,pre-set way to “treat” bipolar disorder; there is only a conversation among specific people that generates knowledge about how things work for those people. The biomedical paradigm diagnoses bipolar disorder through applying a set of criteria in cookbook fashion. Then it generates a list of medications to be applied, also in cookbook fashion. Narrative approaches, on the other hand, generate action plans unique to the people creating them. Biomedicine takes DSM-IV-TR as real and essential. A narrative approach does not avoid it, but, rather, recognizes it as one way of specifying similarities and differences among people, which is somewhat arbitrary, and which can be replaced by multiple other ways. Applying DSM is a process like applying any other categorization system. I personally prefer three-dimensional SPECT scans as generating a more reliable story about which medications might be useful. On the other hand, it is within my repertoire of stories, to recognize that the social environment can radically change the brain and that patterns of neuronal activity, even as found on a SPECT scan, are socially constructed. Without relationship, we would have a useless brain for it would not have matured. Our social relationships can change dendritic connections within the nervous system, can change regional blood flow and metabolism, and can transform the story we tell about who we think we are.

Social Psychologist A.T. Abma (2000) writes that our “interactions and relationships are shaped by dynamic socio-political processes and go through conflicts and impasses.” Thus, the relationships of conventional psychiatrists and people labelled as having bipolar disorder are different from those of us on the periphery – in the outskirts of culture, in the margins where social change begins. I would go as far as to say that our people who get labelled as bipolar quickly become different from their people as a result of the social interaction. The quality of what we learn and come to know depends on the quality of the relational process through which we learn it. .

Conflict is inevitable in relationship, especially with those who have earned the bipolar label. Conflict is more th the absence of consensus but rather the negation or exclusion of "otherness. " I want to tell a story about coming to that realization with a family.

Erin (change name before completion) was a thirty-five year old woman who had lived a fairly ordinary life (with the exception of what was called a manic episode in her 20s that resolved) until two years ago when she abruptly ended a 10 year relationship to be with a man she met on the internet who turned out to be married and have two children. The family’s story about Erin was that she realized too late that this man was unavailable and broke down over the pain of loss of the past relationship and her anticipated future relationship. She had been hospitalized and diagnosed with bipolar disorder. She had been started on medications meant to “treat” this disorder, and none had worked. Erin’s psychiatrist sent her to me when she took maternity leave, but I gathered from subtle hints in her notes (between the lines, so to speak) that she was glad to pass Erin along, since Erin wasn’t responding to her ministrations.

At first, I liked the family’s interpretation of Erin’s story, but I slowly became aware that Erin detested this interpretation. She felt it trivialized her struggles and her pain. She believed that she had been meant to be the Vampire Queen, to ascend to sit at the right hand of God as his Queen. At the last minute, she had been punished by being made to live among the undead (the rest of us) due to her selfishness. When the time came to be called, she had been too selfish and had been tossed aside. She was waiting for an angel to come to take her to her rightful place in the cosmos, which involved dying to eternal life. I thought of Jukka Altoonen at first, and how he would work so hard to bring this story around to one that was more ordinary. I tried that approach, but Erin was insulted by it and accused me of conspiring with her family to torture her. That was when I realized that we had to respect and work within Erin’s story. A colleague suggested that we begin with the notion of time. Perhaps Erin’s sitting by the front window, watching through the glass for her angel, was unrealistic. Perhaps Erin’s sense of time was off. Perhaps she would have to busy herself to make her prison better since angels might not come for 20 years. Since she didn’t want to have an accidental death (to choke or drown or otherwise die through non-ascension), she would have to look toward her physical world for a while. This was a better strategy. It also revealed the family conflict. Everyone (including me at first) was trying to deny the reality of the “otherness” of Erin. We wanted her to make sense in our world of ordinary soap opera drama. We wanted to bring her down from her Wagnerian operatic world into our sordid high schoolish dramas. She refused to be dislodged.

When we acknowledged Erin’s otherness, what emerged was the exhaustion of family members from the work of trying to change her. Within the consultation group in which this family presented itself, the recommendation was to surrender, to stop trying to change Erin, to leave her alone unless she became imminently dangerous to herself. Then the proper course of action would be to call the police to intervene. Otherwise, we were to accept her edict – that she is God and therefore is in control of her destiny. Members of the consultation group offered to pray for Erin and for the family. A suggestion was made for everyone to write letters to God; that they could be given to Erin as origami hangings, like Sodaka’s thousand cranes for world peace in Hiroshima, Japan. A member of the group told about praying for her daughter for 20 years before her daughter found a way out of alcohol and drug problems. “God works slowly,” she said. “Maybe 20 years is not long to God,”she added, reinforcing what we had told Erin – that she might need to revise her timeframe for angelic ascension. We encouraged the family to get their life back and to acknowledge Erin’s fundamental differentness from them. She was not speaking in metaphor or parable. She was telling her story as she experienced it.

My desire to become a psychiatrist began with reading R. D. Laing while still in high school. Laing illuminated the world of madness for me by showing its meaning. For him, psychiatrists and psychotherapists should facilitate the individual, family, and society becoming more aware of emotional, experiential, and existential needs in a way that increased meaning and authenticity. Psychotherapy should improve quality of life and allow individuals to live within families and societies in a life-affirming manner. Madness was a creative response to living within insane conditions and impossible families and cultures. Life within these contexts was ubearable. Madness allowed that unbearable emotion to leak out and be expressed even if cryptically and in gibberish. Laing explained why madness was often found in the more intelligent patients. They were able to comprehend the impossibility of their lives, generating all the more suffering and desire to communicate their condition. The goal of his psychotherapy and psychiatry was to legitimatize and validate experience, allowing his patients to reconstruct and recathect a sense of worth and meaning for their lives within a more sane context.

Experience is important in the life of an individual. How we use our own self and our humanity is an important aspect of diagnosis and treatment. Treatment must manage the anxiety arising from empathy. It must stay afloat upon the tumultuous seas of the shared experience of intense, profound human emotion. Laing’s psychiatry emphasized the use of self instead of biochemicals, the use of one’s own authenticity in a community healing effort.

During medical school, as I began to study my Native American heritage, I discovered that traditional medicine people treated insanity very much like R.D. Laing, but with one essential difference. Their treatment was much more compassionate and supportive than Laing who seemed to sometimes leave his patients adrift in their unmanageable emotions with little direction and few guideposts.

Through the philosophy of the seven directions, a safe path for life could always be found. Through the intervention of the Spirits and the Divine, impossible affect could be contained. Through their reliance upon the Sacred, medicine people could work miracles, quietly disclaiming responsibility, achieving a kind of transparency so that the credit for their work passed through them and on the Spirits who stood behind them.

Native American medicine people seemed more able to work within the domain of intense emotions experienced by those suffering profound mental disorders. These are the profound emotions of major life experiences and transitions. They are the profound emotions stirred up and activated by ceremonies. These emotions profoundly affect the entire family and community, and, are the fuel driving therapeutic change.

Intense life events open portals into the intense emotional world which we humans are capable of entering yet so rarely do. It is the same profound emotional experience that occurs whenever intense and exhuastive work gives birth to a new sense of integration.

In Coyote Medicine I wrote about my introduction to obstetrics through the birth of my daughter, Sorrel. My anxiety about home birth catalyzed a search and discovery that birth is one of the most intense emotional experiences humans can encounter. The power and intensity of birth are unequaled. Then I found a passage from Laing about midwives making the best mental health workers. Whenever possible, Laing recruited midwives to live and work in his London homes for people with schizophrenia and other psychoses. He believed that midwives were best prepared to handle the intense emotions part and parcel to recovery from insanity.

Having experienced birth, this now made sense. During the hours of labor, women live through intense sensations, perceived as pain by many, coupled with intense emotions, sometimes of fear and panic. My wife, Morgaine, a most artful midwife, showed me how she transformed these many possible negative feelings and sensations into a positive and successful birth experience, one that is immensely gratifying to the women and families involved. This skill is the same as what is required to sit with the insane as they reconstitute a self. It is the skill necessary to lead the lost soul through the descent into Hades, to steal that soul back from the dead, and to re-create a life in the living present. What differs is the intermittent nature of birth contractions and its finite length compared to the constant duration of the unbearable affect of psychosis and its potentially infinite duration.

It is this intense emotionality that we as a society so often defend against by delegating institutions, such as hospitals, to deal with life’s profound transitions of birth and death. It is the reclamation of emotional experience that both facilitates a positive birth and allows the mad to become whole again.

Experiencing the natural processes of life, such as birth, is a way of experiencing ourselves as human beings, becoming aware of our own strength within the meaning of life which lies in the primacy and intimacy of personal experience, and personal responsibility for our experience.

Birth, death, and rebirth are classic themes for humanity. To be aware of this is to increase our ability to use these energies to facilitate our own growth and expansion as individuals, families, and societies. Birth and psychosis both present incredible opportunities for psychological growth and development that we should not avoid.

I had wanted to become a psychiatrist to lead patients through the Purgatory of madness. Instead I found myself more often, in my early medical career, working with pregnant women. Through my clinical experience and research, I discovered that women’s powerful emotions of fear or anxiety affected their body’s physiological process of giving birth. Powerful emotions could stop labor or prevent it from starting. Cathartic or healing emotional experience could remove those blocks and allow the process to continue. The family within which the birth occurred have much bearing on how labor would proceed. The more constricted and repressed the family, the more difficult labor could be. Context affected physiology, just as it affects the brain and its neurochemicals and transmitters in schizophrenia.

Birth and labor are particularly intense emotional experiences of magnificent focus which unfold in the unique style of the individual woman giving birth. This style is constructed from the woman’s life attitudes and beliefs about herself. These beliefs and attitudes exist within the context of family relationships,the couple’s relationship where one exists, and any active support systems. Each woman gives birth differently and originally. No two births are alike. Just as each woman is unique and lives life in her own style, so is she in how she births her children.

Similarly no two madnesses are the same, despite DSM-IV. The meaning of madness cannot be found in chemicals or diagnostic nomenclature. Each madness has its own unique meaning which can only unfold within the context of the person’s life who lives that madness, and only becomes understandable by seeing the person against the backdrop of his family and community. Just as each woman gives birth in her own style, each individual recovers from insanity in her own manner. The midwife is more the shepherdess of the energy of healing, keeping the process moving, than deciding where it shall go. Though it is also her responsibility to make sure the flock arrives at a destination and does not fall off the cliff on the way. These are the Native American metaphors of working with insanity: the idea of leading the sheep to greener, higher mountain pastures in the summer, of bringing them down from the high country before the first snows of winter. The Navajo or Dineh shepherd is one of our best teachers of the art of psychotherapy.

Birth is an event to which a laboring woman relates intimately and uniquely, weaving a learning experience all her own. For a woman, birthing itself can be delicately balanced point in time of terrific impact couched within the developing framework of motherhood.

Psychosis and its recovery is often similarly a unique time in which a person shatters and can put together the pieces, learning how to be an entirely different self. Psychosis often occurs at times of developmental shifts, such as the adolescent transition to adulthood or the child’s transition to adolescence. Recovering these periods and shepherding the person through this developmental epoch is like taking them through labor.

Through birth a woman travels from mothering on a purely biological and cellular level, relatively free of conscious effort, while nurturing a developing fetus, to mothering on a conscious, deliberate level of raising a newborn to adulthood. The point of birth is a meeting place of intuitive body knowledge and conscious, logical, mind process. The body knows how to give birth, the mind learns from it, and with the aid of body hormones, a woman proceeds to mother a child consciously and deliberately. After birth, the mother may still need to feed the baby with nutrients from her body, but she does so by deliberately putting the baby to the breast, rather than unconsciously through her placenta, as in pregnancy. This meeting of body and mind during birth creates and releases enormous energy for growth, as it is an opening through which a new soul is born and new relationships are begun. These family relationships continue to expand personal possibilties for infinite variations of psychologial growth, change, and development.

When severe mental illness hits just as when birth breaks down and Cesareans and other interventions become necessary, this meeting of intuitive body wisdom with affect and memory becomes disturbed. Physiology fails to function adequately. The uterus will not contract rhythmically and forcibly. The neurotransmitters falter and dissipate. In each case our interventions are just as brutal -- Cesareans, forceps, vacuum extractors, and intravenous hormone drips versus the chemical straight jackets of the phenothiazines.

Over 20 years ago neuroscientists at the Langley Porter Neuropsychiatric Institute of the University of California at San Francisco, convincingly showed in a random assignment study at a state mental hospital (Agnews State Hospital in San José), that new onset schizophrenia could be effectively treated without medication. The unmedicated patients remained in the hospital longer (up to 6 months), but less than 10% had future breakdowns that required re-hospitalizaiton. The medicated patients left the hospital sooner, but 90% had future breakdowns that resulted in chronic rehospitalization and disability.

Similarly, my colleages and I, showed in a number of studies that hypnosis, psychotherapy, and other techniques of behavioral medicine, could be used to help women at risk have normal births.

Hypnosis and Birth Study American Journal of Clinical Hypnosis 2004

2008-03-10T11:23:00.002-07:00

Here's the study from which I wrote the previous hypnosis and birth paper for Mothering.

Lewis

Hypnosis to Facilitate Normal Birth

Lewis E. Mehl-Madrona, M.D., Ph.D.

Center for Complementary Medicine
University of Pittsburgh Medical Center
and
Department of Family Practice
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

Running Head: Psychosocial Variables and Birth

Key words: Fear, Birth, Birth complications, Cesarean, Anxiety, Stress, Social Support

This research was supported in part by Resources for World Health, Inc., San Francisco, California; the contributions of an anonymous individual private donor from Tucson, and by the United States Air Force. The opinions expressed herein are solely those of the author and do not reflect opinion or official policy of the United States Air Force or the Department of Defense.

Address communication and reprint requests to Dr. Mehl at the Center for Complementary Medicine, Shadyside Hospital, University of Pittsburgh Medical Center, 5230 Centre Ave., SON Bldg., Rm 216, Pittsburgh, PA 15232. Voice: 412-623-1365, fax: 412-623-1029. E-mail: madronalm@ssh.edu and/or mmadrona@aol.com.

ABSTRACT

Background: Prior research by the author showed that psychosocial factors distinguished abnormal from normal birth outcome. The purpose of this study was to determine if prenatal hypnosis could facilitate normal birth.
Methods:
Results: The use of hypnotherapy significantly inhibited negative emotional factors from being related to abnormal birth outcome.
Conclusions: Attention to reducing the impact of adverse psychosocial risk factors through the prenatal use of hypnosis did improve outcome.
INTRODUCTION

In these days of health care reform, an important opportunity exists to explore the utility of psychosocial interventions in improving birth outcome. These interventions are often less expensive than medical procedures and can be provided by non-physicians. One of these interventions is hypnosis.

Labor length and analgesic use have been reported to be decreased when hypnosis is done during pregnancy. [1] Anxiety about and during birth is decreased. [2] The incidence of postpartum depression is lessened.[3], [4] Increased self-confidence, increased calmness during labor, and easier transition into breast feeding has been described.[5] Decreased pain sensation has been reported.[6], [7], [8], [9], [10] Reductions have occurred in the number of complicated births.[11] Babies born have had higher Apgar scores.[12] Hypnosis subjects experienced greater belonging and security during labor, were less afraid of birth, and perceived birth more as a positive event.[13] Hypnosis helped women to be more relaxed during labor and birth, reduced hyperventilation, and increased feelings of participation and mastery.[14] A psychosocial intervention program that included hypnosis reduced the number of cesarean deliveries and oxytocin augmentations or inductions.[15]

Only one published report showed no improvement over Lamaze technique from the addition of hypnosis, though both LaMaze and hypnosis alone lessened pain equally during labor.[16]

Hypnosis has been reported helpful in the conversion of the breech presentation to vertex[17] and in the treatment of premature labor.[18]

The purpose of this research was to address the question of whether high stress and low social support contributed to birth complications and to determine if hypnosis would protect the high stress-low social support woman from developing birth complications.METHODS

Settings and sources of subjects: The author practiced holistic medicine in San Francisco, California, and, later, Tucson, Arizona. As part of this practice, he provided prenatal hypnosis. Two hundred sixty subjects in the first or second trimester of pregnancy were referred for prenatal hypnosis and included in this study. These patients paid for their visits, or their insurance was billed. Data obtained from the was initially obtained for clinical purposes. Referrals came from family phyicians, obstetricians, naturopathic physicians, and midwives practicing in these areas. Patients seen for their first appointment during the third trimester of pregnancy were not included in this study because the author feared that insufficient time would exist to conduct a thorough evaluation and to provide sufficient treatment to alter birth outcome. (Challenging this belief should be the topic of another study.)

During that same time, the author recruited subjects from these same groups of physicians and midwives for a study of psychosocial factors in the prediction of obstetrical risk. These subjects were told that information was needed from them to study how best to predict risk in childbirth. Subjects were paid for completion of questionnaires and for being interviewed. Informed consent was obtained and the study was approved by the author’s Institutional Review Board. Matched, comparison subjects were obtained from this cohort of subjects, who were not referred for hypnosis. Bias was expected to be against the hypnosis subjects, since 1) they came from the same groups of health care providers, and 2), their providers had not identified them as having special needs which could be addressed by hypnosis. There were approximately 2000 subjects from which to match for the comparison group.

Assessment: A complete medical and psychosocial history was obtained from all subjects, including: (1) Demographic information, (2) Complete family medical history, (3) Ob/gyn health history, (4) Psychosocial history, (5) Past medical history, and (6) Review of current symptoms.

The Holmes-Rahe Life Stress Inventory was administered, along with the Taylor Manifest Anxiety Scale, the Dyadic Adjustment Scale, and the Beck Depression Inventory. The couple was interviewed whenever possible. The woman was assessed for her relationship to her body, awareness of body symptoms and patterns of body tension. The scores on the Taylor Manifest Anxiety Scale were normalized to a 0 to 1 scale, as the scores on the Dyadic Adjustment Scale. That scale was oriented so that higher scores meant greater marital satisfaction. The Holmes-Rahe Life Stress Inventory was assessed over the preceding 3 years.

Couples were interviewed whenever possible and during that interview, information was solicited from which an assessment of the couple's beliefs, experiences, expectations and affective states was made. Assessment was also made of the women's stressors, fears and social support. Interview formats and questions are present as Appendix A.

Matching: Subjects in the comparison group were matched with subjects in the hypnosis group so that their values lay within the same intervals defined below:
a) Age: 15-19, 20-24, 25-29, 30-34, 35-39, 40+
b) Socioeconomic status: No insurance, Medicaid, Commercial insurance or HMO, highest level private commercial insurance (ratings of insurance as average or high level was made by the author’s hospital’s billing department independent of this study).
c) Obstetrical risk (defined by the POPRAS system from Harbor General -- UCLA): Low, medium, high.
d) Marital status: Unmarried, married, separated, divorced (at the time of initial interview).
e) Education: Less than 12 years, high school graduate, junior college or college courses, college graduate, graduate courses, graduate degree.
f) Parity: 0, 1, 2, 3, 4+.

Evaluation: Initial interviews aimed to establish close rapport with each subject, so that feelings, fears and complaints could be freely expressed. Interviews usually lasted two hours. Information about the woman's past and current reactions toward herself, her family, partner, work, social, religious and physical experience was elicited. Her knowledge of the physiology of pregnancy and birth, her menstrual experience, family patterns of pregnancy and birth, changes in sexual relationships, attitudes toward body changes, the baby, nursing, and general experiences of pregnancy and birth were assessed.

Note was made of shifts in attitudes and reactions indicated by changes in tempo and intensity of verbalizations, slips of the tongue, innuendo, facial expression, vasomotor activity and tone of voice. Physiological monitoring was included when possible and changes in blood pressure, heart rate, skin conductance, skin temperature and muscle tension were noted when associated with specific subject matter.

The interest or capacity of each woman for participation varied. Some had but little experience thinking about themselves or that which had happened to them and expressed themselves poorly. Some subjects who verbalized poorly gave crucial, pertinent material once encouraged to talk about themselves. Others were defensive and produced scanty material.

These interviews represented different experiences to different patients. To most, they gave a much needed feeling of being an individual in whom others were interested. To a few, the interviews were simply an opportunity to be a part of a study, and to a couple of women, the interviews provided a serious threat. Most of the patients, however, soon came to regard the interview as a helpful experience--an opportunity to talk about anxieties and problems.

Observations of the prenatal care provider were elicited by telephone interview or a data form sent in the mail. Obstetric data and all physical examination findings during the course of pregnancy and childbirth were abstracted from prenatal care records, requested after delivery (the woman signed a records release form during the initial interview). Every effort was made to learn as much as possible about the patients in terms of their psychological functioning, cultural background and life experiences.

Interview records were examined in accordance with Glaser’s method of grounded theory.[19] In this method, qualitative data is examined with an eye toward data reduction. All possible categories which make sense clinically and theoretically are applied to the data. Categories are tabulated and reviewed. Categories are collapsed and combined when possible and logical to obtain a limited and manageable number of variables. A continued coding, sorting, and evaluating process eventually results in a data reduction scheme which makes sense and represents what is available in the data.

For example, the statement, "I am afraid of pain in childbirth", was coded as a fear response. Initially it was called “personal fear of birth, then fear of birth, and finally, fear, as categories were combined. By taking the verbal statements, reviewing any descriptions of associated affective expression, a statement could be made about the intensity of the fear. Statements made were rated on a +3 to -3 scale. "I am afraid of pain in childbirth" became a 'Fear' statement, with a numeral rating assigned to represent its intensity. Appendix B lists the final coding format that developed through the grounded theory process.

The final seven categories to arise from the coding process included:
(1) Fear,
(2) Anxiety-stress,
(3) Maternal self-identity
(4) Beliefs,
(5) Psychosocial support from the partner,
(6) Psychosocial support from the mother's mother,
(7) Psychosocial support from friends.

A team of three clinicians assigned responses to the appropriate category and rated the response for intensity . The frequency of occurrence of a specific response and the magnitude or intensity of the responses were sufficient for clinicians to grade responses from -3 to +3 according to the strength of the statement. Comparative adverbs of 'very', 'mildly', etc., were included as indicators of the magnitude of the psychological state. The verbal responses of the women were differentially weighted in the specific content categories in proportion to the assumed intensity represented by statements made and interviewer notes. Values were assigned to all the verbal responses made. One type of direct verbal report of the subjective affective experience, such as, "I am anxious", would be classified in the 'anxiety-stress' category, and have a weighted value of a -2, while the same statement with a greater intensity, " I am very anxious", could be weighted -3. Each of the women's responses were assessed with the value weighted on each variable to develop a profile of her psychological attitude during pregnancy. The sign of the rating (+ or -) was in accordance with the hypothesized relationships of how this factor would affect the birthing process. The descriptors provided were those which worked for the raters to achieve over 85% agreement. They were developed through rating patients together prior to beginning the study. If the raters could not agree through consensus, the average of their ratings was taken and rounded. The inter-rater reliability was checked on every fifth patient and remained above 0.85.

Treatment: If hypnosis were successful it would be expected to prevent patients with many adverse factors from having abnormal birth complications. If hypnosis was not successful it would be expected to have no impact on outcome.

The general approach used for prenatal hypnosis was oriented toward problem-solving and was perceived as brief, not as insight-oriented nor psychoanalytically-based psychotherapy. Goals included increased relaxation, decreased anxiety, increased sense of trust of social support, realistic fear and a feeling of confidence that the woman could cope adequately with the pain of labor. Visualization was used to guide the woman through an imaginary experience of giving birth, thereby decreasing fear and anxiety. Careful notes were made of the interviews. Audio and videotapes of representative hypnosis sessions are available upon request.

The mean number of prenatal interviews was 5. The mode for number of psychosocial sessions was three. The minimum number was one and the maximum, 60. All hypnosis was provided by the author. Subjects in the comparison group were seen for two-three hours total, usually twice.

Outcome variables: A normal birth was defined as one without obstetrical intervention (no Cesarean, no uterine dysfunction, no fetal distress, no low Apgar scores, no infant resuscitation required, etc). Uterine dysfunction was diagnosed when treated by the doctor or midwife with oxytocin augmentation during labor or with induction. Fetal distress was noted when it was recorded on the labor and delivery record. Apgar scores were recorded on the labor and delivery record. Infant resuscitation efforts were described on the labor and delivery record. All of these were obtained from the hospital records, or, for home birth, from the midwife’s birth records.

An abnormal birth, therefore, required the use of obstetrical technology, including Cesareans, induction and augmentation of labor with oxytocin, fetal distress resulting in intervention or fetal scalp sampling, low Apgar scores, and postpartum hemorrhage. An obstetrician and two certified nurse-midwives reviewed each case to assess normal versus abnormal. They were blind to the existence of this study. They agreed on 95% of cases. For the remaining cases, their consensus was accepted. These were borderline cases in which, for example, blood loss was on the borderline of excessive or fetal distress was on the borderline of being excessive.

Data analysis: The T-test procedure and the discriminant analysis procedures from the Systat statistical package for the MacIntosh computer was used. Statistics provided are already corrected using the Bonferoni method for the number of comparisons made. Chi-square tests were used to test statistical signficance of differences between groups. Variables were compared within the total sample of 520 women by actual outcome group. Then comparisons were reconsidered with subjects grouped by the use of hypnosis or not.

RESULTS

Table 1 compares demographics between women having normal births and abnormal births in this sample. No significant differences were expected between women in the hypnosis and the comparison group, since matching procedures were used. Table 1 shows no signficant differences, either, in demographic variables, when women were compared between for actual outcomes. Age of the total sample of patients varied from 18 years to 39 years with an average of 27 years. Years of education ranged from 9 to 19, with an average of 13 years. Fifty-two percent of the women were primigravidous, 24% were secundigravidous, 11% were having their third child, and 13% were pregnant with their fourth or greater child. No significant differences in level of medical risk were found between subjects who had abnormal outcomes versus normal outcomes. No differences were found in the range of distance from place of birth for women in normal and abnormal outcomes.

Contribution of Medical and demographic variables to risk: Table 2 shows no differences in the two groups for members having previous live births, previous abortions and previous miscarriages. Women in the abnormal birth group showed significantly more previous (to the pregnancy) infections, injuries and hospitalizations. These events were not obstetrical or gynecological and did not increase their risk on the Popras Obstetrical Risk Screening Criteria. There were no differences in number of prior surgeries or diagnosed illnesses. Women in the abnormal birth group showed more frequent past drug use. Neither group was using drugs during the pregnancy. Women in the normal birth group were more physically active.

Emotional state variables. Table 3 shows the differences in the emotional state variables. All four variables were significantly different between groups. Women in the abnormal birth group showed more anxiety-stress and fear. Their beliefs were more negative toward birth. They showed less maternal identity.

Table 4 compares the emotional state variables between the normal and abnormal birth outcome groups, grouped for the use or non-use of hypnosis. The comparison group who did not receive hypnotherapy showed significant differences between anxiety and stress when normal and abnormal birth outcome groups were compared. These differences disappeared when comparisons were made in the presence of hypnosis. The presence of hypnotherapy seemed to inhibit cases of high anxiety-stress who received hypnosis from from having abnormal birth outcomes.

Fear variable. The control group who did not receive hypnotherapy showed significant differences between fear when normal and abnormal birth outcome groups were compared. These differences were still present but to a lesser degree when comparisons were made in the presence of hypnosis. The presence of hypnotherapy appeared to prevent women with high fear who received hypnosis from from having abnormal birth outcomes, but not to the same extent as for anxiety-stress. A significant difference was still present between women having abnormal births and women having normal births, both of whom received hypnotherapy.

Maternal self-identity variable. The control group who did not receive hypnotherapy showed significant differences between maternal identity when normal and abnormal birth outcome groups were compared. These differences disappeared when comparisons were made in the presence of hypnosis. The presence of hypnotherapy seemed to inhibit cases of low maternal identity who received hypnosis from from having abnormal birth outcomes.

Belief variable. The control group who did not receive hypnotherapy showed that negative beliefs about birth were significantly associated with abnormal birth outcome. These differences disappeared when comparisons were made in the presence of hypnosis. The presence of hypnotherapy seemed to inhibit cases of women with negative beliefs about birth who received hypnosis from having abnormal birth outcomes.

Depression (BDI). Among the comparison group, increased Beck Depression scores were significantly associated with abnormal outcomes. Within the hypnosis group, this difference was not signficant, indicating that hypnosis protected against the effects of depression on birth outcome. The greater levels of depression in the normals in the hypnosis group further suggests that hypnosis had a protective effect.

Taylor Manifest Anxiety Scale. Among the control group, increased Taylor Manifest Anxiety Scale scores was significantly associated with abnormal outcomes. Within the hypnosis group, this difference was not significant, indicating that hypnosis protected against the effects of manifest anxiety on birth outcome. The greater levels of manifest anxiety in the normals in the hypnosis group further suggests that hypnosis had a protective effect.

Life Stress Inventory. Among the control group, increased Life Stress Inventory scores were significantly associated with abnormal outcomes. Within the hypnosis group, this difference was not signficant, indicating that hypnosis protected against the effects of high levels of life stress on birth outcome. The greater levels of life stress in the normals in the hypnosis group when compared to normals in the non-hypnosis group further suggests that hypnosis had a protective effect.

Social Support Variables. Table 5 shows differences between normal birth outcome women and abnormal birth outcome women on measures of social support. Higher levels of perceived support from the woman's partner (husband, boyfriend, etc.) was signficantly associated with normal birth outcome. Higher levels of perceived support from the woman's own mother was, intriguingly, significantly associated with abnormal birth outcome. Higher levels of support from the woman's friends was statistically significantly associated with normal birth outcome. Higher levels of marital satisfaction as measured by the Dyadic Adjustment Scale was statistically significantly associated with normal birth outcome.

Support from mother's mother. No statistically significant differences or effects were observed.

Support from friends variable. Lower levels of support from friends were associated with abnormal birth in the presence of hypnotherapy than in its absence.

Marital satistaction. For the control group who did not receive hypnotherapy, higher levels of marital satisfaction were associated with normal births, and low levels with abnormal birth. Statistically significantly lower levels of marital satisfaction were still associated with normal birth in the presence of hypnotherapy.

Birth data. In comparing the mean scores between the normal and abnormal birth outcome groups on birth data variables, first stage labor length, Apgar score at 1 minute, and Apgar score at 5 minutes, significant differences were found as would be expected. First stage labor length was shorter, and the Apgar scores at 1 and 5 minutes were better for the normal birth outcome group than for the abnormal birth outcome group (by definition). No significant differences between the mean scores for the normal and abnormal birth outcome groups were found for gestational age, second stage labor length and birthweight, indicating that premature labor did not figure a role in these differences. These results are summarized in Table 6.

Discriminant function analysis was used to correctly classify 91% of the cases correctly into the normal birth outcome group (group N) or the abnormal birth outcome group (group A). Women having normal deliveries were classified correctly with 90.2% accuracy, compared to 92.1% for women having normal births. The canonical correlation was 0.7808 meaning that about eight times out of ten, correct classification occurred. The most significant psychosocial factors were fear and support from the baby's father and drug use. Hypnosis was signficantly associated with normal outcome.

No one particular practice group was significantly associated with abnormal outcomes, suggesting that practitioner practice patterns were sufficiently similar not to contribute to outcome differences. Practitioners who were willing to refer patients for hypnosis or for a study on psychosocial factors affecting risk tended to be more supportive of natural childbirth and had lower intervention rates than their colleagues who would not participate in making such referrals.

DISCUSSION

Examination of the group of women who were evaluated and not offered hypnotherapy revealed that psychosocial variables were related to abnormal birth outcome. Seven major psychosocial variables showed importance to birth problems. These included maternal stress and anxiety, fear, negative beliefs about birth, negative maternal self-identity. Psychosocial support variables of significance included support from the baby's father, support from friends, and marital satisfaction/dissatisfaction as measured with the Dyadic Adjustment Scale. Depression as measured by the Beck Depression Inventory was asociated with abnormal birth as was manifest anxiety (Taylor Manifest Anxiety Scale), and Life Stress over the past three years (Holmes-Rahe Life Stress Inventory).

Providing hypnosis to women at psychosocial risk (as judged by the above criteria) did seem to help them have a normal birth.

Of surprise was the finding that high levels of support from the woman's mother was associated with abnormal birth outcome. This may indicate that the manner in which we rated this variable keyed more into dependency and passivity, or that women need a different kind of support from their mothers than we imagined in conceptualizing our rating system.

This study shows that a psychosocial intervention program can have a positive effect on birth outcome among women who are having full-term labors. Prenatal providers might do well to incorporate a consideration of psychosocial risk factors during prenatal care and to utilize methods such as hypnosis (or others that may prove effective) to help reduce psychosocial risk during routine prenatal care. This can be done cost-effectively, through utilization of a trained mental health professional. This practitioner can interact with nurses and childbirth educators to improve co-ordination of patient care and provide attention to psychosocial risk. Specifically, psychosocial risk reduction involves:

(1) Identification, acceptance and resolution of fears.

(2) Identification of states of high anxiety-tension, with helping the client learn more effective coping styles.

(3) Identification of negative beliefs about birth and parenting, with provisions for reframing and emotional relearning.

(4) Identification of low maternal identity with anticipatory guidance for the mothering role and hypnotherapy to improve self-esteem.

(5) Consideration of strengths and stresses of the woman's support system. Needed interventions included:

(a) Couple's therapy to decrease stress, increase husband's emotional availability, improve lifestyles, etc.

(b) Individual counseling for the husband to address his unique concerns (when indicated).

(c) Network therapy (environmental intervention with the mother's friends (which can be done in childbirth classes),

(d) Therapy with the mother and her mother to facilitate transition and change of that relationship, and/or,

(e) Helping the woman with no psychosocial support to establish needed relationships and resources.

On a broader level, these findings may presage a time when all medicine is practiced more holistically, with mind-body interventions seen as important. When the way medicine is practiced changes to reflect our new understanding of the interactive nature of all aspects of the patient's life on health and disease, we will have come far.

Table 1. Comparison of means and standard deviations for the demographic variables between normal and abnormal birth outcome groups.
_____________________________________________________________________
Normal Abnormal

Demographic variables Mean SD Mean SD t-value
_____________________________________________________________________
Age 27.42 4.64 28.83 5.09 0.45
Years of education 13.83 2.36 14.50 2.53 0.55
Religion 2.23 2.74 2.45 2.69 0.28
Place of birth 3.82 2.19 3.91 2.92 0.52
Marital status 2.17 1.24 2.30 1.11 0.55
Parity 0.75 0.89 0.79 0.91 0.54
____________________________________________________________

Table 2. Comparison of means and standard deviations for the past obstetrical history variables between normal and abnormal birth outcome groups.
______________________________________________________________________
Normal Abnormal

Past obstetrical
history variables Mean SD Mean SD t-value
______________________________________________________________________
Previous live births 0.72 0.94 0.66 0.83 0.23
Previous abortions 0.85 1.21 0.84 1.10 0.13
Previous miscarriages 0.18 0.33 0.17 0.54 0.07

Past medical history
variables
_______________________________________________________________________
Infections 0.62 0.72 1.25 1.12 2.83**
Injuries 0.32 0.67 0.79 0.77 2.91**
Surgeries 0.65 0.75 1.04 0.73 1.59
Hospitalizations 0.63 0.75 1.35 0.87 2.51*
Illnesses 0.46 0.43 0.83 1.02 1.50

Habit history variables
_______________________________________________________________________
Past Drug Use 0.77 1.16 1.52 1.24 2.30*
Physical Activity 1.34 1.22 0.70 0.80 -2.06*
_____________________________________________________________
*Significant at the 0.05 level (p>+1.96); **significant at the 0.01 level (p>+2.57)

Table 3. Comparison of means and standard deviations for the emotional state factors between normal and abnormal birth outcome groups
________________________________________________________________________
Normal Abnormal

Emotional state factors Mean SD Mean SD t-value
________________________________________________________________________
Anxiety-stress -0.21 1.94 -1.76 1.34 3.40*
Fear 1.16 2.07 -0.83 1.71 4.13*
Maternal Identity 0.95 1.80 0.21 1.76 2.67*
Beliefs about Birth 1.48 1.43 0.23 1.55 3.34*
Beck Depression Inventory 11 9 13 6 1.31
Life Stress Inventory 328 160 444 311 1.05
Taylor Anxiety z-score 0.25 0.23 0.51 0.10 3.93*
_____________________________________________________________

Table 4. Comparison of means and standard deviations for the emotional state factors between normal and abnormal birth outcome groups when grouped for hypnotherapy
______________________________________________________________________

Hypnotherapy No Hypnotherapy

Emotional state factors Mean SD Mean SD t-value
______________________________________________________________________
Anxiety-stress
Normal -1.60 0.69 0.81 2.02 4.09**
Abnormal -1.91 0.59 -1.51 2.05 0.77
t = 1.27 t = 3.18**
Fear
Normal 0.48 2.21 1.68 1.83 1.89
Abnormal -1.06 1.14 -0.74 2.06 0.59
t = 2.10* t = 3.40**
Maternal-Identity
Normal -0.19 1.43 1.91 1.56 3.52**
Abnormal -0.51 1.38 0.03 2.13 0.81
t = 0.48 t = 2.65*
Beliefs
Normal 1.66 1.23 0.87 1.41 1.51
Abnormal 0.19 1.15 0.33 1.40 0.36
t = 1.47 t = 2.89**
Depression (BDI)
Normal 18.1 5.08 9.5 7.4 3.60*
Abnormal 20.2 7.66 14.2 7.2 0.42
t = 0.42 t = 2.70*
Taylor Manifest Anxiety Scale (z-normalized score)
Normal 0.46 0.31 0.11 0.17 5.71**
Abnormal 0.65 0.13 0.59 0.17 0.56
t = 0.89 t = 3.57**
Life Stress Inventory
Normal 544 166 225 71 4.11**
Abnormal 515 219 510 131 0.51
t = 0.15 t = 2.81**
_____________________________________________________
*Significant at the 0.05 level (p>+2.048); **significant at the 0.01 level (p>+2.763)
Table 5. Comparison of means and standard deviations for the psychosocial support factors between normal and abnormal birth outcome groups
____________________________________________________________________
Normal Abnormal

Psychosocial support
factors Mean SD Mean SD t-value
____________________________________________________________________
Partner 1.29 1.40 -0.54 1.96 3.83**
Mother's mother 0.29 1.53 -0.42 1.41 1.89*
Friends 0.92 1.17 -0.12 1.01 3.34**
Marital satisfaction (z-score) 0.61 0.15 0.30 0.13 4.01**
__________________________________________________________
*Significant at the 0.05 level (p>+1.960); ** significant at the 0.01 level (p>+2.576)

Table 6. Comparison of means and standard deviations for the psychosocial support factors between normal and abnormal birth outcome groups when grouped for hypnotherapy
____________________________________________________________________

Normal Abnormal

Psychosocial support
factors Mean SD Mean SD t-value
____________________________________________________________________
Partner
Hypnotherapy 0.50 1.69 -0.40 1.94 1.13
No hypnotherapy 1.74 1.33 -0.63 2.17 3.86*
t = 2.30* t = 0.44
Mother's mother
Hypnotherapy 0.75 1.82 -0.43 1.01 0.95
No hypnotherapy 0.65 1.42 -0.30 1.66 1.67
t = 0.53 t = 0.43
Friends
Hypnotherapy 0.94 1.22 -0.25 0.53 3.16*
No hypnotherapy 0.81 1.27 0.01 1.38 1.85 t = 0.13 t = 0.93
Marital Satisfaction (DAS) (z-score)
Hypnotherapy 0.40 0.23 0.46 0.11 0.91
No Hypnotherapy 0.75 0.22 0.21 0.10 5.22**
t = 2.54* t = 2.03
___________________________________________________________
*Significant at the 0.01 level.

Table 7. Comparison of means and standard deviations for the birth data between normal and abnormal birth outcome groups.
____________________________________________________________________

Normal Abnormal

Birth data Mean SD Mean SD t-value
____________________________________________________________________

Gestation (weeks) 40.08 1.09 40.07 3.94 .1
Labor length (hours)
First stage 6.53 4.99 11.10 8.11 2.64**
Second stage 1.23 3.00 1.60 2.18 0.94
Birthweight (g) 2701.51 395.35 2887.70 529.52 0.41
Apgar scores
1 min 8.56 1.23 7.80 2.06 2.50*
5 min 9.13 1.16 8.36 1.44 -2.12*
___________________________________________________________
*Significant at the 0.05 level; ** significant at the 0.01 level.

*Significant at the 0.01 level (p>+2.576)
*Significant at the 0.05 level (p>+1.96); ** significant at the 0.01 level (p>+2.57)

16 April 1995

Louise Acheson, MD, MS
Associate Editor
Archives of Family Medicine
Bowman Gray School of Medicine
Medical Center Boulevard
Winston-Salem, NC 27157-1084

Dear Dr. Acheson:

I am submitting another manuscript related to hypnosis during pregnancy to the Archives for consideration for publication. The manuscript is entitled "Hypnosis to Facilitate Normal Birth under Adverse Conditions." I have tried to follow all the guidelines of the Archives. The paper is not under consideration for publication elsewhere and I am happy to assign copyright to the Archives if the paper is accepted.

I hope this paper will prove acceptable for publication. I look forward to hearing from you.

Sincerely yours,

Lewis E. Mehl, MD, PhD
Resident and
Research Assistant Professor
Telephone (802) 656-3270
Fax (802) 860-1547Appendix A. Interview format.

APPENDIX B

Ratings for Psychosocial Variables

1. Fear

Very Negative (-3)

A. Labor & birth is a very negative, frightening, ordeal
(no sense of being able to manage the fear with a
quality of life or death panic to the fear).
B. Pain is inevitable, life-threatening, and cannot be
managed.
C. Intense panic about losing control during birth
exists.
D. Uncontrollable panic about abandonment during
pregnancy and birth.
E. Panic about impending motherhood (sense of death of
self with no rewards).
F. Personal conviction of a sense of failure to the
extent of impending doom.
G. Personal conviction of impending doom for the baby.

Negative (-2)

A. Seemingly unresolvable sense of birth leading to
physical damage.
B. Unaddressable fears of pain during labor.

C. Fear of loss of control } difficult
D. Fear of abandonment } / to resolve;
E. Fear of motherhood } all with few
F. Fear of "failing" at birth } \ coping
G. Fear for baby's health } skills

Mildly negative (-1)

Apprehensions about:

A. Labor & birth } minimal
B. Pain } / skills for
C. Loss of control } with managing
D. Abandonment } \ these fears
E. Motherhood }
F. Failure }
G. Baby's health }

Neutral (0)

No codable response

Mildly Positive (+1)

Fears on A. through G. with which the woman is actively attempting to cope, through established coping styles and/or learning new coping styles with research staff.

Positive (+2)

Healthy anticipation for the challenges of A. through G. When fear appears, there are active, working, mature coping styles through which fears are resolved.

Very Positive (+3)

Enthusiastic anticipation of the challenges of A. through G. with excellent coping skills and very realistic expectations.

2. Anxiety-stress

Very Negative (-3)

A. Severe conflict in significant relationships.
B. Excessive fatigue and lack of energy in the face
of stress.
C. Significant depression in the face of stress.
D. Intense externally directed responses under stress
(blame, aggression, projection).
E. Highly unstable living situation.
F. Significant somatization during stress (headache,
back pain.
G. High levels of unmanageable anxiety.

Negative (-2)

A. Moderate conflict
B. Moderate fatigue & lack of energy
C. Moderate depression
D. Moderate external responses
E. Moderately unstable living situation
F. Moderate somatization (nausea, tension)
G. Moderate levels of anxiety

Mildly negative (-1)

Mild levels of A. through G.

Neutral (0)

No codable response

Mildly positive (+1)

A. Significant relationships are somewhat harmonious.
B. Energy is somewhat available for coping with
anxiety-stress.
C. Low levels of happiness and contentment are described.
D. Anxiety and stress are handled through internally
directed processes, including relaxation and seeking support
and assistance.
E. Living situation has more stability than not.
F. Coping styles are generally successful at resolving
stress without somatic effects.
G. Anxiety and stress is overall tending toward
management and resolution.

Positive (+2)

A. Harmonious significant relationship.
B. Energy is available.
C. Happiness and contentment are described.
D. Stress and anxiety are managed through internal means
which work well for the woman.
E. Stable living situation.
F. Successful coping styles.
G. Anxiety and stress is managed and resolved.
3. Maternal Self-identity

Very Negative (-3)

A. The woman feels forced into motherhood against her will.
B. The woman is very oriented toward career & believes
that child will ruin her career (major identity).
C. The woman feels repulsed by thoughts of the fetus and is
alienated from the experience of being pregnant.
D. The woman cannot imagine herself as a mother and feels
very unsure and insecure about the prospect.
E. The woman is convinced she will be a very poor mother
and will damage her child.
F. The woman feels great shame at being pregnant and
about motherhood.

Negative (-2)

A. The woman is resentful at having been manipulated into
motherhood.
B. The woman's primary identity is her career. Motherhood
seems incompatible.
C. The woman expresses antagonism toward the fetus and
regrets being pregnant.
D. The woman feels insecure about becoming a mother.
E. The woman worries she will not be a good mother.
F. The woman feels shame at being pregnant and about
motherhood.

Mildly Negative (-1)

A. The woman vascillates on her decision to have a baby.
B. The woman tends away from identifying as a mother,
feels unready for motherhood.
C. The woman feels unprepared for the fetus.
D. The woman is somewhat insecure about becoming a
mother.
E. The woman is somewhat concerned that she will not
mother well.
F. The woman is embarrassed about pregnancy and
motherhood.

Neutral (0)

No codable response

Mildly Positive (+1)

A. More than less, woman feels accepting of her
pregnancy.
B. Woman is working toward accepting her identity as a
mother.
C. Woman is working toward acceptance of the baby.
D. Woman is working toward becoming comfortable with the
reality of motherhood.
E. Woman is beginning to accept that she will mother adequately.
F. Woman is working toward feeling good about pregnancy
and motherhood.

Positive (+2)

A. Accepting of her pregnancy
B. Acceptance of identity as a mother
C. Acceptance of the baby
D. Comfort with reality of motherhood
E. Acceptance that she will be/is a good mother
F. Feeling good about being pregnant and becoming a
mother

Very Positive (+3)

A. Enthusiastic acceptance
B. Enthusiastic identification with being a mother
C. Enthusiastic welcoming of the baby
D. Excitement about the reality of motherhood
E. Valuation of herself as a excellent mother
F. Feeling very proud about becoming a mother

4. Beliefs:

Very Negative (-3)

A. All pain is very bad, even life-threatening.
B. Birth is disgusting, repulsive, even life-
threatening.
C. People are evil, always untrustworthy, and should
be shunned and avoided.
D. Motherhood is a degrading, awful, humiliating
experience.
E. Work is the only means of achieving worth, and having
a baby destroys that.
F. Deep inside, I am worthless and unimportant,
and am lucky to be permitted even to exist.
G. There are no comforts or sources of help anywhere.

Negative (-2)

A. Pain is bad.
B. Birth is an unpleasant experience that you go through
to get a baby.
C. People are usually unhelpful and often untrustworthy
and not to be relied upon.
D. Motherhood is an unpleasant experience.
E. Work is the major source of personal worth; having a baby
will erode that.
F. I am an inferior person deep inside; nobody could really
truly love me.
G. If there are sources of strength and assistance,
they're not available for me.

Neutral (0)

No codable response

Mildly Positive (+1)

A. Pain is frightening, but can be accepted and worked
with.
B. Birth is frightening, but I'm learning I can overcome
those fears.
C. People have let me down, but I'm starting to learn to trust.
D. Motherhood has seemed negative in the past, but I'm
learning that I can make it a positive experience.
E. Work has always been very important to me, but I'm
learning it's not everything.
F. I'm starting to learn how to really trust and love
myself.
G. I'm beginning to draw on inner sources of strength
that I never knew I had.

Positive (+2)

A. Pain can be healthy and can be worked with as part of
a satisfying experience.
B. Birth is a positive experience.
C. Other people provide a support in times of need.
D. Motherhood is a positive experience.
E. I will balance in a gratifying manner motherhood with
all my other life activities.
F. I trust and love myself much of the time.
G. I draw on inner sources of strength when in need.

Very Positive (+3)

A. Pain is a healthy challenge which I will handle and
will grow with.
B. Birth is an exciting and wonderful experience.
C. Other people are a real source of strength, comfort,
and support to me.
D. Motherhood is the most wonderful experience of a woman's
life.
E. I'm really excited to experience the integration of
mothering and work.
F. I trust and love myself and am a very worthwhile
person.
G. I'm constantly nourished by inner, spiritual resources.

5. Psychosocial Support from Baby's Father

Very Negative (-3)

A. Overtly hostile relationship
B. Extreme conflict present
C. Father is actively rejecting
D. No intimacy; no contact
E. No communication
F. No marriage or relationship
G. No skills at conflict resolution

Negative (-2)

A. Covert hostility with occasional eruptions into overt
hostility
B. Moderate conflict present
C. Father is removed and distant
D. Low levels of intimacy; live separate lives with
little contact
E. Very poor communication
F. Very unhappy with marriage
G. Minimal skills at conflict resolution (conflict is
generally not resolved)

Mildly Negative (-1)

A. Mild hostility present
B. Mild conflict present
C. Father is generally unemotional, but present
D. Occasional intimacy, but generally separate
E. Poor communication
F. Unhappy with marriage
G. Conflict is resolved, but with threat to the
relationship

Neutral (0)

No codable responses

Mildly Positive (+1)

A. Attempting to work on reducing hostility present
B. Working to resolve conflict in the relationship
C. Father working to become more emotionally
available in the relationship
D. Couple is actively working to improve intimacy
E. Couple is working to improve communication
F. Couple is working to improve problems that contribute to
their marital satisfaction
G. Couple is learning to resolve conflict without
threatening the relationship

Positive (+2)

A. Partner is generally accepting of the other and the
pregnancy
B. Couple is in harmony with each other
C. Father is interested and involved in the pregnancy
and birth plans
D. Trust, intimacy, and closeness are dependable parts of
the relationship most of the time
E. Good communication exists most of the time
F. Overall sense of marital satisfaction despite the
existence of some problem areas
G. Ease of conflict resolution without threat to the
relationship

Very Positive (+3)

A. Partner is very accepting of the woman and the pregnancy
B. High levels of harmony exist; for example, baby may
have been planned together
C. Father is thrilled about the pregnancy and baby
D. Very high levels of trust and intimacy are present
E. Excellent communication of emotions, including anger
and love
F. Very high levels of marital satisfaction
G. Strength of the relationship allows resolution of conflict
before problems arise

6. Psychosocial Support from Mother's Mother

Very Negative (-3)

A. Very negative statements about childbirth, such as
"birth will rip your insides out" or "women die in
childbirth," or that mother's mother almost died in
childbirth
B. Parenting is a very negative experience
C. Mother's mother refuses to have anything to do with
her once she is pregnant
D. No contact; no intimacy or sharing
E. No communication
F. Very strong childlike dependency
G. Very actively rejecting

Negative (-2)

A. Mostly negative statements about childbirth
B. Parenting is a negative experience
C. Mother's mother avoids contact
D. Contact is superficial
E. Poor communication
F. Mother is overprotective and fosters dependency
G. Mother's mother is anxious and rejecting

Mildly Negative (-1)

A. Mildly negative statements about childbirth, such
as women lose health and beauty from pregnancy
B. Parenting is mildly negative experience
C. Woman is stressed and anxious in presence of her mother
D. Sharing exists at the level of concern about mother's
mother's reactions and disapproval
E. Communication is indirect
F. Relationship fosters feelings that mother's mother is
strong and mother is weak
G. Mother's mother is mildly disapproving

Neutral (0)

No codable response

Mildly Positive (+1)

A. Mother is mildly positive about birth
B. Mildly positive about parenting
C. Can turn to mother for support when in crisis
D. Sometimes can share intimately with mother
E. Sometimes easy and good communication exists
with opportunity for clarifying feelings
F. Generally adult relationship, with return to mother-child
relationship when in crisis
G. Mother is conditionally accepting with periods
of genuine warmth

Positive (+2)

A. Positive statements about childbirth
B. Positive statements about parenting
C. Mother is available for support
D. Mother and daughter maintain a good relationship with
intimacy and sharing
E. Good, direct communication
F. Consistent, adult-adult relationship with
opportunities for both to give and receive
G. Mother is warm and accepting

Very Positive (+3)

A. Very positive statements and enthusiasm about
childbirth
B. Very positive statements and enthusiasm about
parenting
C. Mother is very available for support
D. Very good opportunities for intimacy and sharing
E. Excellent, direct communication
F. Very strong personal friendship
G. Very close ties with warmth and acceptance

Positive (+2)

A. Positive statements about childbirth
B. Positive statements about parenting
C. Good friendships available for support
D. Good friendships with intimacy and sharing
E. Good direct communication
F. Adult give and take relationship
G. Strong social support system (friends organize baby
shower, etc.)

Very Positive (+3)
A. Very positive statements and enthusiasm about childbirth,
describing it as a joyous experience
B. Very positive statements and enthusiasm about
parenting
C. Excellent friendships, very available for support
D. Very good opportunities for intimacy and sharing
E. Excellent, direct communication
F. Adult give and take relationships with opportunities for both
to be weak and strong
G. Excellent social support system (friends involved in
birth preparations and plans)

[1] Harmon TM, Hynan MT, Tyre TE. Improved obstetric outcomes using hypnotic analgesia and skill mastery combined with childbirth education. Journal of Consulting and Clinical Psychology 1990; 58(5): 525-530.
[2] Mairs DAE. Hypnosis and pain in childbirth. Contemporary Hypnosis 1995; 12(2):111-118.
[3] McCarthy P. Hypnosis in obstetrics. Australian Journal of Clinical and Experimental Hypnosis 1998; 26(1):35-42.
[4] Harmon TM, Hynan MT, Tyre TE. Improved obstetric outcomes using hypnotic analgesia and skill mastery combined with childbirth education. Journal of Consulting and Clinical Psychology 1990; 58(5): 525-530.
[5] Sauer C, Oster MI. Obstetric hypnosis: Two case studies. Australian Journal of Clinical and Experimental Hypnosis 1997; 25(1):74-79.

[6] Dillenburger K, Keenan M. Obstetric hypnosis: an experience. Contemporary Hypnosis 1996; 13(3): 202-204.
[7] Barber J. A brief introduction to hypnotic analgesia. In Barber J (Ed). Hypnosis and suggestion in the treatment of pain: A cliical guide. New York: Norton, 1996, pp. 3-32.
[8] Oster MI. Psychological preparation for labor and delivery using hypnosis. American Journal of Clinical Hypnosis 1994; 37(1): 12-21.
[9] D’Eon JL. Hypnosis in the control of labor pain. In Spanos N, Chaves J. (Eds). Hypnosis: The cognitive-behavioral perspective. Buffalo: Prometheus Books, 1989, pp. 273-296.
[10] South TL. Hypnosis in childbirth: A case study in anesthesia. In Lankton SR, Zeig JK. Treatment of special populations with Ericksonian approaches: Ericksonian monographs, No. 3. New York: Brunner/Mazel, 1988, 00. 16-24.
[11] Rossi EL, Cheek DB. Mind-body therapy: Ideomotor healing in hypnosis. New York: Norton, 1988
[12] Harmon TM, Hynan MT, Tyre TE. Improved obstetric outcomes using hypnotic analgesia and skill mastery combined with childbirth education. Journal of Consulting and Clinical Psychology 1990; 58(5): 525-530.
[13] Tiba J, Frater J, Balogh I, Bognarne-Varfalvi M. Combining psychotherapeutic methods in preparing mothers for delivery. Magyar Pszichologiai Szemle 1985; 42(3) 223-230.
[14] Wormnes B. The use of hypnosis in childbirth. Tidsskrift for Norsk Psykologforening 1984; 21(6); 285-293.
[15] Mehl L., Donovan S., Peterson G.: The role of hypnotherapy in facilitating normal birth. In Fedor-Freybeigh P, Vogel MLV (eds.) Prenatal and Perinatal Psychology and Medicine. Park Ridge, NJ: The Parthenon Publishing Group, 1990.
[16] Venn J. Hypnosis and Lamaze method -- an exploratory study: A brief communication. International Journal of Clinical and Experimental Hypnosis. 1987; 35(2): 79-82.
[17] Mehl L. Prenatal hypnosis for conversion of breech presentation to vertex. Archives of Family Medicine 1994.
[18] Mehl LE. Psychobiosocial intervention in threatened premature labor. Pre- & Peri-Natal Psychology Journal 1988; 3(1): 41-52.
[19] Glaser B. Grounded Theory. San Anselmo, CA: The Sociology Press, 1977.

Diabetes study one page summary

2008-03-05T22:05:00.001-07:00

Here's the diabetes study I am trying to get going.

Lewis

Diabetes is a serious health problem and especially so for aboriginal people. Most efforts to improve diabetes among aboriginal people have failed. Spirituality is an important and understudied aspect of health and disease, both in terms of coping with illness, management of stress, and the possibility of direct spiritual healing. Previous research among Pima Native Americans in Arizona showed that a control group condition consisting of education in Pima culture and spirituality was actually helpful in improving diabetes control compared to the treatment condition (best American Diabetes Association diabetes disease management education and accompanying clinical services), which resulted in worse diabetes control.
We propose to investigate the effect of enhancing spirituality among primarily Aboriginal people (Native Americans in U.S. terminology) on the primary outcome of glucose control for type 2 diabetics. Secondarily, we will (1) assess the effect of enhancing spirituality on quality of life among primarily aboriginal diabetes, (2) characterize spirituality of modern day aboriginal people, both using psychometric instruments (all of which will be further validated for use with aboriginal people) and qualitative methods, including descriptions of the process of increasing spiritual fluency and practice, and characterization of any instances of spiritual transformation.
Specifically, our proposal consists of three aims: 1) A community level analysis of the effects upon diabetes control of increasing local spiritual literacy; 2) a person-based qualitative study within these communities of how increasing spiritual literacy translates into what is typically called spirituality, healing, and spiritual transformation within a primarily Aboriginal context; and 3) an individual level analysis of how increasing spirituality and spiritual literacy defined both qualitatively and quantitatively is associated with glucose control among diabetics. To accomplish this, we will match pairs of communities for culture/language group and for distance from major urban centers (the best predictor of diabetes prevalence for communities in Quebec). We will work through our Department of Family Medicine’s Northern Medical Services unit to implement community focus groups to consider implementation of the two programs to be studied – spiritual enhancement versus diabetes knowledge translation. Equal resources will be available to each community to hire community members as participatory researchers (community health liaisons), to pay spiritual leaders or diabetes health educators, to pay their assistants (singer/helpers or other educators), and to provide support for community members to participate in regular meetings (childcare, food, transportation, supplies). A participatory framework will be followed with community members enrolled as collaborative participants in collecting stories about people’s experiences, completing questionnaires, and gathering medical data. The community health liaisons will be community members who will coordinate (in collaboration with our Project Coordinator and post-doctoral fellows) story collection, questionnaire completion, and will take people to the health clinic when necessary for medical measurements. They will obtain medical data (with permission of participants) from the medical clinics. A strength of our project is the existence of a Nationalized Health Service which will pay for all necessary laboratory studies since we are followed Canadian Diabetes Association Best Practices guidelines for diabetes management in our scheduling of testing. The presence of only one health clinic in each of the communities also strengthens our capacity to obtain longitudinal data.
Programs will be randomized to communities (maintaining matched pairs). The primary outcome variable is glycohemoglobin level. Secondary outcome variables include microalbumin levels in urine, blood pressure, body mass index, LDL and HDL cholesterol levels, and triglycerides. Secondary psychosocial outcome variables include quality of life measures, anxiety, depression, and indices of spirituality and religiosity. Qualitative methods will include narrative analysis and modified grounded theory with dimensional analysis.
Quantitative data analysis will be accomplished with hierarchical linear modeling techniques using the medical outcome measures as dependent variables and treatment groups as independent variables with adjustments for potential confounding variables. Qualitative data analysis will be accomplished by local panels of experts ranking stories in order of increasing spiritual literacy in that local version of spirituality. These rank orderings will then be subjected to nonparametric statistical analysis with glycohemoglobin change as the dependent variable. More classical narrative analysis techniques will also be used.

Bipolar Disorder

2008-02-24T00:14:00.001-07:00

Here are my thoughts on bipolar.

Bipolar Disorder

The contemporary concept of bipolar disorder provides fertile ground for exploring the interfaces among mind, brain, body, relationship, environment, spirit, and culture. But what is bipolar disorder? Is it a thing, like a rock or a liver? Is it a convenient word? Is it a firm biological reality or is it a cultural construct riding upon the waves of an uncertain biological sea? Is it more plot than condition; strategy, than a thing; verb, than a noun?
The conventional story about bipolar disorder. The conventional story about bipolar disorder is a consensual one, forged by psychiatrists and other mental health professionals in collaboration with patients, the media, and the pharmaceutical companies. It developed through communication and dialogue. People learned to recognize the signifiers of bipolar disorder within themselves and to present them to professionals. Whatever the underlying biology of bipolar disorder is, the communication about it and the development of its signifiers and the learning by the population to assume that label and present themselves to professionals, and the response by professionals – all of that is highly cultural laden. Given the predominant cultural concept that genetic or biological illnesses require pharmaceuticals, then that is what is offered. But there are alternate strategies for all conditions and modes of suffering – traditional Chinese medicine, for example, uses needles, herbs, massage, diet, and counseling. Traditional North American healing uses ceremony, prayer, massage, herbs, and more, whether for arthritis or for excessive and prolonged sadness.
In the conventional story bipolar disorder is a chronic disease affecting over 2 million Americans at some point in their lives. The American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" describes two forms of bipolar disorder, type I and type II.[1] In type I, there has been at least one full manic[*] episode.* In type II, periods of "hypomania" involve less severe manic symptoms that alternate with at least one major depressive episode. People who suffer from bipolar disorder are thought to have pathological mood swings from mania to depression, with cyclic patterns of exacerbation and remission.
The Social Construction of Mood. Culture enters when we encounter mood. Mood is not an object like a table. We must learn how to describe the emotions that characterize mood. Cultures recognize and enact emotions differently. Mood varies from family to family and from culture to culture.
The developmental psychologist Vygotsky believed that we learn to reflect upon our emotional state by internalizing conversations with others and conversations that others have about our emotional states. Through repeating these conversations to ourselves we come to think of them as our own.
I suspect that the youngest children feel without words. They live an unbroken stream of experience. When they exhibit behavior that significant adults in their lives can interpret, a pointing or labelling process begins. A significant adult says, “Oh, so you’re sad.” Now a category appears and the unbroken experience becomes organized into a concept called sadness. As children learn words and language, they learn to label their internal states in some correspondence with the way “they appear to be feeling” to the adults who care for them. Families define sadness in different ways as do cultures. Some languages even lack words for sadness. Similarly, behavior can become labelled as excitement or as irritability in a sophisticated exercise in pointing. The adult points at the child and says a word to label what the child is doing and experiencing. The child learns to equate the word with his internal experiences associated with the word and begins to say that he feels sad or excited or irritable. A major project in negotiating love relationships is the collaborative mapping of what words for emotions mean in one family with what the same words mean in another family. My sadness may bear little resemblance to yours.
All the thoughts we "can think and the mental operations [we] can perform have their source in some … interpretive community."[2] The range, complexity, and subtlety of our thought, its power, the practical and conceptual uses to which we can put it, and the issues we can address result from the degree to which we have been initiated into the knowledge communities to which we belong. "Human thought is consummately social: social in its origins, social in its functions, social in its form, social in its applications.[3] The thoughts and feelings that come to be labelled as bipolar disorder are initially social.
Values, habits, emotions, manners of behaving at the table, and spitting are transmitted through social interaction. Erasmus[4] wrote manuals of good behavior to codify social interaction. Conversely, social interaction produces patterns of behavior.
Throughout our childhood, and even before birth, we are a lifelong process of negotiation. Even infants engage in conversations with their mothers and other caretaking adults through crying, smiling, and through their eyes. Because their well-being depends on understanding their mother's language, both verbal and gestural, infants are interpreting these conversations with their mothers (and other caretaking adults) as soon as they can register and distinguish changes in physical attitude and gesture, tone of voice, and facial expression. And because a mother's well-being depends in part on understanding and adapting to her infant's needs, infant and mother are, to that extent, knowledgeable peers. Together they compose a unique but culturally crucial knowledge community whose members are learning from each other as they go.
Vygotsky[5] wrote a classic description of this process of community composition and collaboration that involved a six-month-old infant. The infant saw an attractive object—a shiny spoon—and extended his hand to grasp it. The spoon was out of reach. For a moment, Vygotsky said, the infant's "hands stretched toward that object, remaining poised in the air. His fingers made grasping movements." The infant appeared to be trying, at the most elemental level, to establish contact with a bit of physical reality. Shoved around by the physical world, he shoved back. He wanted a response from the object or a relationship with it that corresponded to his reaching out for it. But the object did not cooperate in the effort to be known. Objects never do. For a moment, then, the infant reached and nothing happened.
“Then something did happen. The object still didn't cooperate, but mother did. The infant's mother moved the object closer, so that the infant could feel it, look at it, and put it into his mouth.”
This brief, mundane scene provides a key to understanding knowledge and collaborative learning. When infants reach for an object, they do not merely reach. They send a message. When a caretaker gets the message and responds, infants learn indelibly the importance of this seemingly irrelevant side effect. Our first effort to grasp an object, Vygotsky tells us, is the first step we take in learning to point. Pointing, Vygotsky argues, “is an unsuccessful attempt to grasp something, a movement aimed at a certain object which designates forthcoming activity. . . . When the mother comes to the child's aid and realizes that his movement indicates something, the situation changes fundamentally. Pointing becomes a gesture for others. The child's unsuccessful attempt engenders a reaction not from the object he sought but from another person[6].
Vygotsky tells us that knowing is not an unmediated, direct relationship between us and an object. We need other people’s involvement in order to know something. Other people are always involved in our learning processes. The infant in Vygotsky's illustration eventually learns to know and master the shiny spoon through learning how to make an adult respond to give it the spoon. Infants begin to "understand [their grasping] movement as pointing," Vygotsky says, when they understand that their "object-oriented movement" has really become "a movement aimed at another person, a means of establishing relations."[7] Learning always involves relationships with other people. The experience is collaborative because, when they finally get the message and respond, the caretakers have understood the infant. They have learned a gestural word or phrase with which the infant is now able to converse. They have learned to expect forthcoming activity from the infant. From the infant's point of view, they have learned to obey orders.
These moments in the lives of six-month-old infants contend seriously for the attention of college and university teachers, because the process implied can be traced from infancy through childhood to the learning of adults. Infant and mother learn what they need to know about each other by internalizing the language that constitutes their community, encapsulating the results of their ongoing conversations in conventions and routines. As infants grow and learn, becoming children and then adolescents and adults, they incrementally nest membership in that first, small, closed knowledge community of mother and child, expanding toward communities with which to pledge allegiance.[8]
Vygotsky described the actions of a four or five-year-old child trying to take possession of a piece of candy by figuring out how to use some basic tools to advantage, in this case a stick and a stool. As the child worked, she talked through her solution to the problem. But she did not talk in a state of fantasy involvement with the objects that concerned her. She talked about them, and about herself, to someone. Sometimes she talked to another person at hand. Most of the time, she talked to herself as if she were another person.
Vygotsky said that the child was using social speech instrumentally, to get something done. By the time she was four or five, much of her "socialized speech (which had previously been used to address an adult) had turned inward.” Rather than appealing to the adult, she appealed to herself.[9]
Vygotsky observed children talking to themselves as if they were talking to someone else. Eventually, they did talk to themselves silently and private thoughts emerged. He wrote that "every function in [our] cultural development appears twice: first, on the social level, and later, on the individual level; first, between people . . ., and then inside."
Children and adults interact to shape and change each others’ responses. Learning and understanding emerge as individuals create and accomplish interactive tasks in everyday conversations. Bamberg calls this talk-in-interaction. We learn as we go. In this same spirit, people learn to recognize their emotions and to talk about their emotions through interactive dialogue with each other. Knowledge about sadness cannot be separated from the conversation going on between the people involved. "Knowledge" is not separate from "society." Instead, we see "trials of strength"1 in which knowledge, conversation, emotional involvement, and social relationships are inseparable. By exercising her native talent for linguistic improvisation, a young child translates and retranslates until she gets it "correct."
Intuitively we know this. In a classic Gunsmoke episode, a mother has run away from her gunslinger husband when she discovers that she is pregnant. This is so her child will not grow up to be like his father. The drama unfolds when the gunslinger rides into town and recognizes his wife and realizes he has a child. He leaves when he realizes that she is right – the child will grow up to be just like him if he stays or if he takes his family with him. Vygotsky’s insights show us how we learn our emotional strategies as we grow up within our families. This argument suggests that the emotional strategies and negotiations that come to be labeled as bipolar are socially learned through ongoing interactive processes in families and shape the brain and its connections as they go. Genetic susceptibility may also play a role that remains to be determined (twins separated at birth help us to tease this out), but the observation that the bipolar strategy runs in families is not evidence for its genetic basis but for its existence in social learning. (We will shortly consider biology and genetics.)
A correct response or emotion is what is acceptable to the community in which the child lives. Membership in a community means that everything we do is unhesitatingly correct or incorrect according to specific criteria within that local community.
The child interacts with the important adults in her community to learn how to correctly point to sad, angry, irritable, mad, and all the other labels available in that community. Eventually she internalizes these conversations. At first, she talks to herself. Soon she thinks to herself without the need for talking. She learns about emotions and their proper expression.
As we mature, we internalize conversations about emotions as thoughts. The fact that we tend to re-externalize thought under stress as direct or indirect conversation (talk and writing) demonstrates the continuing relationship of thought and conversation in adult learning, even when that relationship ceases to be readily apparent. It is stress that occasions our talking to ourselves ("Don’t let yourself feel so sad.”). It is stress that occasions the rap sessions and endless dorm-room talk typical of adolescence and early adulthood."[10]
Having made that digression into how children learn to categorize emotional experience, to carve it up from the unbroken whole, and how they learn to be emotional and express emotions, returns us to the possibility that being manic (which is defined as elevated mood, hyperactivity, over-involvement in activities, inflated self-esteem, a tendency to be easily distracted, and little need for sleep) may be learned. We may learn how to enact mania as a strategy for communication. Perhaps it is a partially successful strategy that gets carried away with itself? Once learned, perhaps we cannot stop. Depression typically follows mania, with its accompanying loss of self-esteem, withdrawal, sadness, and even risk of suicide. I suspect we also learn how to do depression – when to label ourselves as depressed. We learn what useful functions depressive actions play in social life, and how to be depressed. Mania and depression may also be like light and darkness, the opposites that must co-exist.
Modern psychiatry's recognition of bipolar disorder comes from Kraepelin's 1921 application of the term “manic-depressant insanity” to cyclic episodes of mania alternating with depression, a syndrome which has been recognized in various forms for over 2000 years [Barclay RM (trans), Robertson GM (ed). (1921). Manic-Depressive Insanity and Paranoia. Edinburgh, E & S Livingstone.]The profession introduced the term “bipolar disorder” in the mid-1970s in a largely unsuccessful attempt to lessen confusion between this condition and schizophrenia [Kupfer DJ. Epidemiology and clinical course of bipolar disorder. In Kupfer DJ (ed.) Bipolar Disorder: The Clinician’s Reference Guide. Montvale, NJ: Clinical Psychiatry LLC, 2004.]
In the conventional story, bipolar disorder appears between the ages of 15 and 25, affecting men and women equally. From 1.2 percent13 to 1.6 percent [Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 51:8-19, 1994.]14 of the US population is diagnosed as bipolar with prevalence increasing. The recognized incidence is thought to be an underestimate because of underreporting and under-recognition of manic and hypomanic episodes. The dominant discourse of modern psychiatry recognizes pharmacological treatment as the mainstay for bipolar disorder.
The symptoms consist of alternating episodes of mania and depression. In the manic phase, we see an increase in goal-directed activities (either socially or at work), increased energy, distractibility, flight of ideas or subjective experience that thoughts are racing, an inflated self-esteem or grandiosity, an increased involvement in activities that may be pleasurable, but may have dire consequences (e.g., spending sprees), a decreased need for sleep (person feels rested after 3 hours of sleep). The patient may be more talkative than usual or may feel pressured to speak. He may be easily agitated or irritated and may lack self-control
Hypomanic episodes are similar but less intense. Delusions, if present, are congruent with mood (such as delusions of grandeur, or a sense of special powers and abilities).
In the depressive phase people experience persistent sadness and depressed mood; feelings of hopelessness, worthlessness, pessimism, and "emptiness"; loss of interest or pleasure in activities that were once enjoyed, including sex; sleep disturbances; motor slowing or agitation; withdrawal; feelings of guilt and worthlessness; fatigue; overwhelming sluggishness; difficulty concentrating, remembering, or making decisions; loss of appetite and/or weight loss, or overeating and weight gain; and thoughts of death or suicide.
If delusions are present, they are typically congruent with mood (such as delusions of worthlessness or accusing voices). In "atypical depression," people sleep more than usual and have increased appetite.
Conventional medicine usually hospitalizes people who are having acute symptoms so that medications may be started to control the symptoms. These medications include neuroleptics (antipsychotics), antianxiety agents (such as benzodiazepines), anticonvulsants, and antidepressant agents. The conventional story involves other people only as support group members or in educational sessions about the illness.
Biological models for bipolar depression have focused largely on the effects of uncontrollable stressors [Swann AC. (2006). Neurobiology of Bipolar Depression in El-Mallack RS, Ghaemi SN.(eds.) Bipolar Depression: A comprehensive guide. Washington, DC: American Psychiatric Publishing, Inc., pp. 37 – 68.] These models have moderate pharmacological validity but lack any specificity for distinguishing types of depression (routine or unipolar depression from bipolar depression, for example) [Machado-Vieira R, Kapczinski F, Soares JC. (2004). Perspectives for the development of animal models of bipolar disorder. Prog Neuropsychopharmacol Biol Psychiatry 28: 209-224; Nestler EJ, Gould E, Manji J. (2002). Preclinical models: status of basic research in depression. Biol Psychiatry 52: 503-528.] The core depressive symptoms are indistinguishable between bipolar depression and unipolar depression [Mitchell P, Parker G, Jamieson K. (1992). Are there any differences between bipolar and unipolar melancholia? J Affective Disorders 25:97-105.] On average people with bipolar depression are more slowed down and experience more lack of energy than people with unipolar depression [Katz et al 1982; Kupfer et al 1974] though some studies contradict this [Mitchell et al, 1992]. These differences are not diagnostic, and, in fact, the two depressions cannot be distinguished by symptoms [Benazzi 2003b; Katz et al, 1982]
Another emerging type of depression is called a mixed depression in which the symptoms of depression are accompanied by two or more symptoms of mania [Benazzi 2003a]. The presence of manic symptoms does help to distinguish somewhat, with two manic symptoms present in 78.1% of people with bipolar depression and 41.5% of people with unipolar depression. Three manic symptoms were present in 46.6% of bipolar depressed people compared to 7.6% of unipolar depressed people [Benazzi 2001]. Contrary to popular belief, the presence of anxiety and inner tension is ubiquitous in all depressions [Benazzi et al 2004; Katz et al 1982; Wolff et al 1985]. What does suggest bipolar depression is the presence of the other manic symptoms, such as increased goal-directed activity, grandiosity, hypersexuality, or true racing thoughts [First et al 1996; Frank et al 2002; Swann et al 1993], Increased norepinephrine function has been found in predominantly manic mixed states compared with pure depressive episodes [Swann et al 1994].
All studies considered, it has been impossible to determine if depression, bipolar or otherwise, stems from too little or too much of any neurotransmitter [Maas et al 1991]. A second generation of unsuccessful hypotheses implicated imbalances between neurotransmitters, such as norepinephrine versus serotonin [Prange et al 1974] or norepinephrine versus acetylcholine [Janowsky et al 1972]. A third generation of unsuccessful hypotheses held that second messenger function associated with neurotransmitter receptors with increased activity during mania [Lachman and Papolos, 1995; Stewart et al 2001].
There is a state-dependent elevation of norepinephrine in manic and mixed states, but no reliable changes in norepinephrine or it metabolites during depression [Swann et al 1987; Koslow et al 1983]. Norepinephrine is apparently metabolized differently during depression with lower relative concentrations of its intracellular metabolites, consistent with increased pulsatile releases [Maas et al 1987; Swann et al 1987] in mania. A mathematical calculation (the D-score) of different amine metabolite levels does discriminate between bipolar I depression, bipolar II depression, and other depressions [Grossman and Potter, 1999; Schatzberg et al 1989]
People with bipolar depression appear to have increased reactivity to norephinephrine. Moreso in bipolar than in unipolar depression, norepinephrine is related to mood and “slowing down” [Swann et al 1990], treatment response [Maas et al 1984] and relationship to stressful events [Swann et al 1990]. People with bipolar depression have increased sensitivity to the subjective effects of stimulants [Anand et al 2000]. Pharmacologically increased norepinephrine precipitates mania in people with bipolar depression [Price et al 1984] and may selectively improve bipolar depression [Osman et al 1989]. People with bipolar disorder have a greater noradrenergic response to orthostasis [Rudorfer et al 1985], having more noradrenergic neurons in the locus coeruleus [Baumann and Bogerts, 2001].
3-met04 hoxy-4-hydroxyphenylene glycol (MHPG), the major metabolite of norepinephrine, is low among patients with bipolar depression, suggesting a role for central norepinephrine in this disorder.[iv]. One-fourth to one-half of MHPG is derived from the central nervous system and the remainder from the adrenal medulla and the sympathetic nervous system. The most common endocrine finding is excess cortisol, resulting from excess secretion of corticotrophin releasing hormone, which is stimulated by norepinephrine and acetylcholine, and inhibited by GABA. Hypercritical, exploitative and emotionally unresponsive environments can feature as important precursors. Chronic stress early in life in vulnerable persons is thought to predispose them to both bipolar and ordinary depression.
Studies of serotonergic function are consistent with reduced functional capacity but are not specific [Price et al 1991; Sher et al 2003; Sobczak et al 2002]. Indepependent of all else, lower serotinergic function may be related to potential suicidality [Goodwin and Post, 1983; Mann, 1999], though the relationship may be stronger in unipolar than in bipolar depression [Stokes et al 1984]. Corticospinal fluid cortisol concentrations and degree of dexamethasone suppression test nonsuppression are related to depressed mood, especially in mixed states, among people with bipolar depression [Swann et al 1992]. Sensitivity to norepinephrine does appear to differentiate bipolar from unipolar depression along with blunted responses to 5-hydroxy-tryptophan in non-depressed people and abnormal behavioral responses to tryptophan depletion in relatives of people with bipolar depression.
Recent studies suggest that the disturbances in bipolar depression may relate to systems involved in neuronal adaptations to changes in activity or second messenger systems, including the nitric oxide system [Akyol et al 2004]. One indirect study showed lower blood arginine levels and higher nitrite levels among people with bipolar depression [Van Calker and Belmaker 2000; Yanik et al 2004]. Cell-signaling systems, particularly involving inositol and protein kinase C may be involved in the action of so-called mood stabilizing drugs [Harwood and Agam 2003]. Systems involved membrane lipids, such as the arachidonic acid cascade, may be important [Rapoport 2001].
Subtle abnormalities in arousal, lateralization, and susceptibility to impulsivity have been found among people with bipolar depression[Buchsbaum et al 1977; Brocke et al 2000; Hegerl et al 2001; Dubal et al 2000]. Abnormalities in arousal or in sensitivity to neurotransmitters may be related to abnormal regulation of ion distribution [Whybrow and Mendels, 1969]. Active transport is reduced per sodium pump site in cultured, lymphoblastoid cells from Old Order Amish people with bipolar depression compared with nonaffected relatives or controls [Cherry and swann, 1994]. The response of the active transport of sodium to increased sodium influx maintains membrane potential over time in excitable cells, provides the cation gradient that drives uptake processes for neurotransmitters and other compounds and is the major cause of activity-dependent energy utilization [Stahl 1986]. This process is diminished in cells from people with bipolar disorder [Li and El-Mallakh 2004]. Inhibition of the active transport of sodium by ouabain leads to abnormal hippocampal cell excitability [El-Mallakh et al 2000] and increased motor activity in ras [El-Mallakh et al 1995, 2003].
Several studies have found alterations in glial density in people with bipolar depression when compared with normal controls, including reductions in the subgenual part of the anterior cingulate cortex [Chana et al 2003] and the subgenual part of the prefrontal cortex [Ongur et al 1998]. Glial cells are responsible for glutamate clearance. A build-up in glutamate from reduced clearance could result in overexcitation of neurons [Schurr 2002; Schurr et al 1997a] with consequent excitotoxicity [Lipton, 2004]. Neuronal loss has been found in layer III of the dorsolateral prefrontal cortex [Rajkowska et al 2001]. Glial cell loss in the amygdala was only evident in people who had not been treated [Bowley et al 2002]. A glial specific protein, the alpha2 subunit of the sodium potassium ATPase pump, has been found to be reduced in the temporal cortex of people with bipolar depression [Rose et al 1998].
Impairments in fine motor function are found in all depressions, but are more closely linked to noradrenergic function and to severity of the depression among people with bipolar depression [Swann et al 1999]. Treatment response [Maas et al 1984] and sensitivity to stressful life events [Swann et al 1990] are more strongly related to norepinephrine among people with bipolar depression.
In the story of neuroimaging, we are seeking replicable findings associated with specific behavioral states. To date few neuroimaging findings have been replicable from laboratory to laboratory. [Neuroimaging Studies of Mood Disorder Effects on the Brain. Yvette I. Sheline. Biol Psychiatry 2003;54:338–352.]

Diagnoses
Associated with Size of Temporal Lobe Other
Depression Ventricles changes Changes
Bipolar depression
Reduced size of prefrontal cortex
(Coffman et al 1990; Schlaepfer et al 1994; Strakowski et al 1993)

Reduced prefrontal grey matter independent of treatment of mood state, bipolar or unipolar
(Drevets et al 1998 in Swann)

Reduction in total cortical volume (DelBello et al 2004)

Increased size of amydgala (Altshuler et al 1998); Decreased size of amydgala (Pearlson et al 1977)

No cortical grey matter loss
Dupont et al 1995; Harvey et al 1994; Pearlson et al 1997; Schlaepfer et al 1994; Zipursky et al 1997.

No change in amygdala size (Swayze et al 1992)

Decrease in cortical grey matter, intermediate betweel control and schizophrenics
(Lim et al 1999)
Increased lateral ventricle size
Swayze et al 1990; Figiel et al 1991; Strakowski et al 1993

Mixed results for size changes in thalamus
(Dupont et al 1995; Strakowski et al 1993)

Reduced volume of amygdala in adolescents (DelBello et al, 2004 in Swann)

Reduced signal intensity in the corpus callosum consistent with neuropsychological reports of switching (Pettigrew and Miller, 1998) (Branbilla et al 2004 in Swann)
Reduced temporal lobe size
(Altshuler et al 1991)

Decreased Hippocampal size (Altshuler et al, 1991)

No difference
Harvey et al 1994; McDonald et al 1991

Mixed results for size changes for hippocampus
(Altshuler et al 1998; Hauser et al 1989; Swayze et al 1992)

Increased right hippocampal volume correlated with poor cognitive functions (Ali et al 2000 in Swann)

Loss of normal asymmetry
Swayze et al 1992

Increased size on left and in size of amygdale and striatum:
Harvey et al 1994

No difference in size
Johnstone et al 1989). Strakowski et al (1999)

Chronic lithium treatment prevents volume loss
(Manji et al 2000)

Enlarged cortical sulci (fissures on the surface of the brain) found in middle aged (Lim et al 1999)

Decreased numbers of glial cells in the prefrontal cortex
(Ongur et al 1998)

Larger caudate nucleus size in males
(Aylward et al 1994)

Larger globus pallidum volume with no change in striatal volume
(Strakowski et al 1999)

No differences in caudate, putamen, lenticular nuclei (Dupont et al 1995; Strakowski et al 1993; Swayze et al 1992)

Increased white matter hyperintensities, decreased cerebellar size, and increased sulcal and third ventricular volumes (Stoll et al 2000 in Swann)

No relationship with hyperintensities (Brown et al 1992; Sassi et al 2003 in Swann)
Bipolar with multiple episodes of mania

Lateral ventricular enlargement
Strakowski et al 2002

Post-Stroke Syndromes
Decreased size of Hippocampus, amygdala, basal ganglia, frontal cortex associated with depression
(Starkstein and Robinson 1989)

Parkinson’s Disease

Decreased size of Hippocampus, amygdala, basal ganglia, frontal cortex associated with depression
(Cummings 1992)

Epilepsy
Decreased size of Hippocampus, amygdala, basal ganglia, frontal cortex associated with depression
(Sawrie et al 2001)

Alzheimer’s Dementia
Decreased size of Hippocampus, amygdala, basal ganglia, frontal cortex associated with depression
(Burns et al 1990)
Decreased size of parietal cortex
(Kanne et al 1998)

Huntington’s Disease
Decreased size of Hippocampus, amygdala, basal ganglia, frontal cortex associated with depression
(Folstein et al 1983)

Major unipolar depressoin

7% overall reduction in frontal lobe volume (Coffey et al 1992)

48% reduction in volume in the subgenual prefrontal cortex (Drevets et al 1997)

Subgenual prefrontal cortex glial cell loss (Ongur et al 1998)

Rostral orbitofrontal cortex decreases in cortical thickness, neuronal size decrease, and loss of glial cells in layers II to IV (Rajkowska et al 1999)

Reductions in glial and neuronal cells throughout all layers, as well as reduction in cell size, were reported in dorsolateral prefrontal cortex
(Rajkowska et al 1999)

Increased volume in the right amygdala (Bremner et al 2000)

Increased volume in bilateral amygdala in first episode subjects (Frodl et al 2002b)

Loss of normal amygdalar asymmetry (Mervaala et al 2000)

Reduction in the bilateral core nuclei of the amygdale (Sheline et al 1998)

Decreased volumes of basal ganglia structures in major depression, especially in late-onset depression (Greenwald et al 1997; Husain et al 1991; Krishnan et al 1992; Steffens and Krishnan 1998)

No changes in caudate and putamen volume in depressed subjects who were otherwise physically healthy (Lenze and Sheline 1999), a criterion not clearly present in other studies.

Hippocampal volume loss
(Bell-McGinty et al 2002; Bremner et al 2000; MacQueen et al 2003; Shah et al 1998; Sheline et al 1996, 1999), but not in bipolar depression (Geuze et al 2004)

No change in hippocampal volume
(Ashtari et al 1999; Axelson et al 1993; Mervaala et al 2000; Swayze et al 1992)

Reductions in hippocampal volumes
(Vakili et al 2000)
Early-onset depression
Hippocampus, amygdale, basal ganglia, frontal cortex

Late-life depression
cortical and subcortical atrophy
(Pantel et al 1997; Rabins et al 1991; Rothschild et al 1989; Soares and Mann 1997)

Diffuse and ventricular enlargement
(Pantel et al 1997; Rabins et al 1991; Rothschild et al 1989; Soares and Mann 1997)

Higher rates of neuropsychological impairment and greater treatment refractoriness
(Alexopoulos et al 2002; Simpson et al 1998)
Hypertension
Associated with brain atrophy
(Kobayashi et al 1991)

Cushing’s disease
Associated with brain atrophy
(Starkman et al 1992)

Diabetes
Associated with brain atrophy
(Aronson 1973)

Alcohol abuse
Associated with brain atrophy
(Charness 1993)

Overall the structural imaging studies described above suggest that there are anatomical abnormalities that may exist relatively early in bipolar depression, but their functional and diagnostic significance is uncertain (Kanner 2004 in Swann).
The prefrontal cortex plays a key role in thinking, also modulating emotional centers of the basal ganglia and limbic regions. A two-armed circuit of brain areas has been proposed as being involved with depression. One arm consists of a limbic-thalamic-cortical branch and is composed of the amygdala, the hippocampus, the dorsomedial nucleus of the thalamus, and the medial and ventrolateral prefrontal cortex. A second limbic-striatal-pallido-thalamic branch is proposed as the other arm of this circuit. The caudate and putamen (striatum) brain areas along with the globus pallidus are organized in parallel to connect with limbic and cortical regions.
One hypothesis (Swerdlow and Koob 1987) about the depressive symptoms of bipolar disorder says that it results from disinhibition of the limbic striatum from underactive forebrain dopamine activity, thereby producing overinhibition of the ventral pallidum with decreased inhibitory connection with the dorsomedical thalamus, which, in turn, results in disinhibition of the excitatory loop involving the mediodorsal thalamus, prefrontal cortex, and amygdala. This is thought to underlie the guilty ruminations, motor slowing, and recurrent thoughts of death found in depression. It does not relate to decreased attention and impairment in executive functioning (Degl’Innocenti et al 1998). The brain story is fascinating and can be seen parallel to the cultural story. What we quickly forget is how biological understanding does not restrict us to biological causality. Biology is inseparable from culture – the major point of this work.
The neurological diseases associated with depression involve damage to brain structures critical in emotional functioning -- namely the frontal cortex, hippocampus, thalamus, amygdala, and basal ganglia. These same brain structures are involved in classical and early-onset major depression (Jellinger 1999). Deoxyglucose metabolism studies using positron-emission tomography (PET) have demonstrated selectively decreased activity in the caudate and orbital-inferior frontal lobe (Mayberg et al 1990). Ischemic lesions located in the anterior frontal cortex were associated with more severe depression (Robinson et al, 1983 and Lipsey et al, 1983). Subsequently, inconsistent results have been reported on the relationship between infarct site and depression after stroke, with systematic review of the numerous studies not supporting the hypothesis that stroke lesion location predicts depression (Carson et al 2000). A strong correlation has been found between lesions affecting the prefrontosubcortical circuits, particularly on the left, and with subsequent depression (Vataja et al 2001).. Among individuals with cognitive impairment, baseline depression was associated with a threefold increased risk of dementia. In vivo MRI studies (Steffens et al 2002) have shown that small left hippocampal size predicts later dementia.
Late-age depression is characterized by a lower prevalence of affective disorders in other family members (Baron et al 1981), greater medical morbidity and mortality (Jacoby et al 1981), and higher rates of neuroradiological abnormalities, particularly white-matter hyperintensities (Coffey et al 1988; Figiel et al 1991).
Any condition which produces neuronal ischemia or neurotoxicity can potentially contribute to brain atrophy.
Some of the MRI volumetric findings in frontal cortex could be accounted for by neuropathological changes such as these. The prefrontal cortex is particularly important as a target of monoamine projections and abnormalities in monoamine receptors, transporters, and second messenger systems (Arango et al 1995; Biver et al 1997; Duman 1998; Mintun et al 2000; Price 1999) are reported to occur in major depression. Another possibility is that overactivation in one part of the interconnected LCSPT neuroanatomical circuit may lead to overexcitation in the other components, resulting in excitotoxic damage. The orbitomedial prefrontal cortex has high concentrations of glucocorticoid receptors, potentially rendering it vulnerable to stress-mediated damage
Hippocampal volume loss appears to have functional significance with an association between acute depression and abnormalities of declarative memory (Burt et al 1995) and recollection memory (Mac-Queen et al 2003), as well as an association between depression in remission and lower scores on tests of verbal memory (Sheline et al 1999). In one study (Shah et al 1998), hippocampal atrophy was found in patients with chronic depression but not in patients with remitted depression. Vakili et al (2000) also observed correlations between depression severity and hippocampal volumes, although no group differences between depressed and control subjects. In one study (Frodl et al 2002a), white matter changes were noted but no overall differences in hippocampal volume. In most of these studies that assessed depression severity in unipolar subjects and used high-resolution MRI techniques, depression was associated with hippocampal volume loss, ranging from 8% to 19%. Studies which only measured the hippocampus/ amygdala complex found no differences. A recent postmortem study (Bowley et al 2002) has found glial cell loss in the dentate gyrus of the hippocampus as well as in the amygdala in major depression. In addition, a recent study has found increased neuronal and glial cell packing density (Stockmeier et al, unpublished data), suggesting a decrease in the hippocampal neuropil in MDD.
Potential Mechanisms for Volume Loss in Recurrent Depression. Approximately half of depressive episodes are associated with elevated cortisol levels. Hypothalamic-pituitary-adrenal (HPA) axis dysfunction can produce repeated episodes of hypercortisolemia in depression. Volume studies do not routinely include measures of cortisol and cannot determine past episodes of hypercortisolemia. In addition to elevated cortisol levels, several different mechanisms could potentially explain volume loss, including neuronal loss through exposure to repeated episodes of hypercortisolemia, stress-induced reduction in neurotrophic factors, stress-induced reduction in neurogenesis, and glial cell loss, resulting in increased vulnerability to glutamate neurotoxicity. Glucocorticoid (GC)-mediated neurotoxicity (Sapolsky 2000) with repeated hypercortisolemic episodes of depression giving rise to atrophy of affected structures is a mechanism that could potentially account for hippocampal, amygdala, and prefrontal cortex volume loss, all areas which have high concentrations of GC receptors; however, it is also well known that the hippocampus has structural plasticity, driven by excitatory amino acids and facilitated by glucocorticoids. In animal studies (Watanabe et al 1992), hippocampal apical dendrites shortened by a single GC exposure or restraint stress returned to normal after 3 weeks. In Cushing’s disease, following successful surgery and a return to normal for GC levels, previously smaller hippocampal volumes returned to normal (Starkman et al 1992; Bourdeau et al 2002). Thus, up to a point, plasticity may be at least partially reversible. Early life stress may produce a permanent hypersensitivity to stress, with the production of ongoing HPA axis dysregulation, particularly in subjects who develop depression (Heim et al 2000). With repeated episodes, plasticity may give way to permanent damage. Inverse correlations between the total amount of time patients have been depressed and hippocampal volume found in some studies (Bell-McGinty et al 2002; Mac-Queen et al 2003; Sheline et al 1996, 1999) but not all (Bremner et al 2000) support recurrent depressive episodes having an antecedent or causal relationship. In addition, a study by Lupien et al (1998) demonstrated a correlation between higher cortisol levels measured longitudinally and greater hippocampal volume loss in normal human aging. A study of first episode patients identified memory impairment on neuropsychological testing but no hippocampal volume loss, whereas multiple episode patients in the same study had both memory impairment and volume loss (MacQueen et al 2003). Thus, while neurotoxic damage may occur, plasticity would permit return of function if the right intervention were used in time.
Excitatory connections between the amygdala and hippocampus (White and Price 1993) raise the possibility that damage in one structure could produce damage in the connected structure. Also, interconnections between prefrontal cortex and hippocampus (Carmichael and Price 1995) could produce excitotoxic damage. Glial cells sequester glutamate, maintain metabolic and ionic homeostasis, and produce trophic factors, including brain derived neurotrophic factor (BDNF) (Ransom and Sontheimer 1992; Szatkowski and Attwell 1994). Thus, loss of glial cells could increase vulnerability to neurotoxic damage, supporting the idea that glutamate neurotoxicity may be involved in the volume loss in the limbic-cortical-striatal-pallidal circuit.
Either directly or indirectly, glial cell loss is another potential mechanism for producing volume loss. Gray matter atrophy has been reported in the prefrontal cortex in an area ventral to the genu of the corpus callosum (Drevets et al 1997), an area associated in postmortem studies with glial cell loss (Ongur et al 1998). Glial cell loss has been found in two different areas of prefrontal cortex (Rajkowska et al 1999), as well as in the amygdala and the hippocampus (Bowley et al 2002) in postmortem studies of major depression.

Stress-induced inhibition of neurogenesis (Gould et al 1997) may also explain depression-related volume loss. Psychosocial stress has been shown to suppress neurogenesis in the tree shrew (Gould et al 1997). Corticosterone treatment in adult rats also produced suppression of neurogenesis, which was reversed by removal of the adrenal gland (Cameron and Gould 1994). It is also possible (Gould et al 1999) that neurogenesis may occur in the frontal cortex in addition to the hippocampus and subventricular zone.
PET Scan studies in bipolar depression

Mood Induction Studies
Anhedonia
Elicited emotion
Prefrontal cortex

Dorsolateral pre-frontal cortex

Frontal poles

Ventral cortex

Reduced glucose metabolism (also unipolar depression)
Ketter et al 2001; Strakowski et al 2000, in Swann)

Negative correlations (Dunn et al 2002)

Reduced N-acetylaspartate levels (Winsberg, et al 2000) (correlated with reduced neuronal integrity.

Correlates negatively with 2-deoxyglucose uptake in unipolar depression (Dunn et al 2002)
Increased responses to both positive and negative stimuli compared to unipolar and controls (Lawrence et al 2004 in Swann)

Increases responses to both positive and negative stimuli (Lawrence et al, 2094
Cerebellar vermis
Increased activity
(Ketter above in Swann)

Ventral cingulated-cortical-limbic activity

Changes found similar to those of controls, especially those with depressive temperaments (Keightley et al 2003 in Swann)

Mobilizing additional subcorticla and limbic areas (Malhi et al 2004).
Insula and claustrum

Negatively correlated with 2-deoxyglucose uptake (Dunn et al 2002 in Swann)

Anterior cingulated cortex

Positively correlated with 2-deoxyglucose uptake (Dunn et al 2002 in Swann)

Supracallosal cingulated gyrus

Negative correlation with 2-deoxyglucose uptake (Dunn et al. 2002)

Basal ganglia

Abnormal choline metabolism (Strakowski et al 2000)

Anterior cingulate gyrus

Abnormal choline metabolism (Moore et al 2000 in Swann)

PET studies suggest three levels of specificity: subjects with negative affective states regardless of diagnosis (Keightley et al 2003 in Swann), depressive subjects regardless of polarity (Dunn et al, 2002; Ketter et al 2001 in Swann), and bipolar subjects regardless of affective state (Ketter et al. 2001 in Swann). The studies suggest poorly regulated affective responses, possibly resulting from the failure of the prefrontal cortex to modulate subcortical and temporal signals (Strakowski 2004, 2005 in Swann). While some abnormalities can be found early (Delbello et al 2004), others develop later (Strakowski et al 2004).
While physiological and receptor imaging abnormalities in bipolar disorder are less well established, noteworthy findings that await replication include elevated resting amygdala activity which correlates with stress related plasma cortisol levels (Drevets, Ann Rev Med 49:331-361; 1998); abnormal blood flow responses to viewing facial expressions of emotion in the amygdala, basal forebrain and inferotemporal cortex; reduced dopamine D1 receptor radioligand binding in the frontal cortex (Suhara et al. 1992); increased striatal uptake of [11C]- N-methylspiperone, a dopamine D2 receptor ligand among psychotic bipolar people relative to controls and non-psychotic bipolar subjects (Pearlson et al. 1995).
Bipolar depression has a more recurrent course (Angst et al 2003; Kessing and Andersen, 1999) with earlier onset (Akiskal et al 1994; Benazzi 2002, 2004; Kessing, 1999), and more frequent episodes (Angst et al 2003; Goldberg and Harrow, 2004; Kessing, 1999; Kessing and Andersen, 1999; Winokur and Wesner, 1987). Rapid fluctuations between high and low can occur in either form of depression, but is more common in bipolar depression (Wolpert et al 1999).
Kindling and sensitization models have been proposed to account for the recurrent nature of bipolar depression (Antelman et al 1998), implying that early episodes would be more likely to be associated with environmental stressors and later episodes becoming progressively more autonomous. This turns out to be true for both unipolar and bipolar depression (Swann et al 1990).
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The The rates of concordance in monozygotic twins ranges from 47% to 70% (Craddock N, Jones I. 1999. Genetics of bipolar disorder. J Med Genet. Aug;36(8):585-94) compared to only 14 percent of dyzygotic twins.11 [NEJM Aug 11 1988; 319(6 part 1)348-53, Aug 18 1988; 319(7 part 2):413-20.] The approximate lifetime risk of bipolar disorder in relatives of a person with bipolar disorder are: monozygotic co-twin, 40-70 percent; first degree relative, 5-10 percent (Craddock and Jones, 1999); and unrelated person , 0.5-1.5 percent.12 [Psychiatric Ann Jul 1989; 19(7):354-59]. Among offspring of a parent with bipolar disorder, 51% were found to have a psychiatric disorder and the risk for bipolar was increased with earlier onset in the parent (Chang et al 2000). The age of onset appears to get earlier in successive generations ( Rice et al 1987). Unipolar depression is increased in families with bipolar depression (Gershon et al 1982). An epidemiological study found an association of mania and major depression in twins, and only a small effect on heritability of major depression if a history of mania was removed, consistent with a continuum model for inheritability for unipolar and bipolar depression (Karkowski and Kendler, 1997). In a study of 67 bipolar (30 monozygotic) and 176 unipolar (68 monozygotic) twin pairs, heritability of bipolar depression was reported to be 85%, with 71% of the genetic risk for mania not shared for depression (McGuffin et al 2003).
Genetic Studies. No clear area has emerged for heritability for bipolar depression, and multiple alleles have been proposed – in fact, several on every chromosome (Hayden and Nurnberger, 2006) The search for genetic anomalies in the alleles regulating neurotransmitter systems has larger been negative (Swann, 2006). A form of the serotonin transporter gene appears to be related to response to SSRIs in both unipolar and bipolar depression (Lerer and Macciardi, 2002; Serretti et al 2004). Neither tryptophan hydroxylase alleles nor serotonin receptor 1A, 2A, and 2C were related to lithium responsivity (Serretti et al 1999, 2000). The incidence of a form of the %5-HT2C receptor was reported elevated in both unipolar and bipolar depression (Lerer et al 2001). No differences were found between controls, people with unipolar depression, and people with bipolar depression in alleles of the 5-HT1B receptor (Huang et al 2003), 5-HT2A (Massat et al 2000; Ni et al 2002), 5-HT5A (Arias et al 2001), serotonin transporter (Cusin et al 2001; Mansour et al 2005) and tryptophan hydroxylase (Cusin et al 2001).
No genetic differences have been found between unipolar and bipolar depressed people (or normal controls) in any of the catecholamine enzyme or receptor systems genes (Swann, 2006). One study associated the LL allele of the COMT (catechol-O-methyl transferase) gene (which has low activity, leading to reduced extracellular breakdown of catecholamines) with rapid cycling (Papolos et al 1998). The A1 allele of the D2 dopamine receptor gene was associated with increased risk for substance abuse (Noble 2000). A form of the D4 dopamine receptor gene was associated with delusions in either unipolar or bipolar depression (Serretti et al 1998b).
Genetic investigations of GABA-A receptors (Coon et al 1994; Serretti et al 1998a), corticotrophin releasing hormone synthesis (Stratakis et al 1997) and proneurotensin synthesis (Austin et al 2000) have all yielded no results.
A dinucleotide repeat of the brain-derived neurotrophic factor (BDFN) is associated with increased risk for childhood-onset mood disorders (Wood et al 2003). BDFN is important in neural adaptations to stress and also has antidepressant properties in animal models (Hashimoto et al 2004). In family based studies the val66met allele was associated with bipolar disorder (Neves-Perreira et al 2002; Sklar et al 2002) and childhood onset bipolar disorder (Geller et al 2004), but it did not distinguish bipolar, unipolar, or normal controls in case-control studies (Nakata et al 2003; Neves-Pereira et al 2002; Oswald et al 2004)or identify children with childhood-onset mood disorders in case control studies (Wood et al 2003). This form of BDNF was also associated with childhood obsessive compulsive disorder (Hall et al 2003) which may be related to risk for bipolar disorder (Chen and Dilsaver, 1995; Thomsen, 1992).
Clock genes have been associated with increased recurrence in bipolar depression (Benedetti et al 2003) and with age at onset (Benedetti et al 2004). A form of GSK-3-beta may be protective, but has a low frequency (Benedetti et al 2004).
Brain tissue studies show evidence of abnormal regulation of receptor second messenger signaling, but not in the receptor binding sites themselves for thalamic glutamatergic systems (Clinton et al 2004). Reductions have been found in a group of synaptic proteins called complexins in schizophrenia and bipolar depression, but not in unipolar depression (Eastwood and Harrison, 2000). Expression of the CREB gene was increased in suicide victims, regardless of diagnosis (Young et al 2004).
Conventional Treatments. Various texts have been written about conventional therapies [El-Mallakh RS, Ghaemi SN. (2006) Bipolar Depression: A comprehensive guide. Washington, DC: American Psychiatric Association Press.] so that it is not necessary to repeat that information here. For conventional therapies, I am partial to the Texas Medication Algorithm [ref], which has been shown effective in a number of studies and superior to psychiatrists working without an algorithm. The only addition I personally make to that Algorithm is to use quietapine (Seroquel) also as monotherapy for bipolar depression related to recent studies showing its efficacy [ref]. I prefer lamotrigine due to its fewer side effects, but recognize that quietapine is thought to have a more rapid onset of actions. For the purposes of this book, I would prefer to focus on the uncertainties which remain in treatment and the potential role that alternatvec could play as either adjuncts to conventional treatment or replacements. \
What must be emphasized about conventional treatments is that success is often partial, non-responders are common, treatments wear off, and side effects can be serious and debilitating. Depression and depressive cycling remains a substantial problem for about two-thirds of intensively treated bipolar outpatients (Post [Post RM, Leverich GS, Nolan WA. (2003). A re-evaluation of the role of antidepressants in the treatment of bipolar depression: data from the Stanley Foundation bipolar network. Bipolar Disorder 5: 396-406.]
For example, in a study on the use of aripiprazole for acute bipolar mania [Keck PE, Marcus R, Tourkodimitris S, Ali M, Liebeskind A, Saha A, Ingenito G, Aripiprazole Study Group (2003). A Placebo-Controlled, Double-Blind Study of the Efficacy and Safety of Aripiprazole in Patients with Acute Bipolar Mania. Am J Psychiatry 160: 1651-1658], an agent which I do use in conventional settings when the need arises, the response rate was only 40% (compared to a 19% response rate for the placebo). The trial was only three weeks, which leaves open the question of medication wearing off. The reduction in symptom severity on the Young Mania Scale when from 8.2 to 3.4, which means that people were, on average, still symptomatic, albeit less so. Only 42% of patients studied completed the three week trial (compared to 21% with placebo), meaning that the majority of the patients did not or could not remain on this medication. Of course, the exclusion criteria eliminated the more severe patients (as drug studies usually do). For example, anyone with mania lasting more than 4 weeks was excluded. Anyone who might need another medication was excluded (how this could be known in advance puzzles me). Anyone who was contemplating suicide or had taken illicit drugs or drank too much alcohol was excluded. As usual, the majority of the patients I see would be ineligible for inclusion in this study. Only 31% of total patients completed the trial, meaning that over two-thirds of patients discontinued double blind treatment. Twenty-one percent of patients were switched to open label treatment (13% of those receiving drug and 28% of those receiving placebo), 10% discontinued because of an adverse reaction (11% for drug, and 10% for placebo). Eleven percent discontinued for lack of efficacy (10% with drug; 12% with placebo), and 27% were lost for “other” reasons, including withdrawing consent, disappearing, or being deemed unreliable.
The adverse events in the drug group consisted of three people becoming more manic, one decompensating, one overdosing on sedatives, and one becoming hypertensive. People receiving placebo reported agitation, accidental injury, chest discomfort, syncope, and urticaria. The list of adverve events appears below, and is typical for these types of studies:
Adverse Event
Placebo
N (127)
Group
%
Aripiprazole
N (127)
Group
%
Headache
40
31
46
36
Nausea
13
10
29
23
Dyspepsia
13
10
28
22
Somnolence
6
5
26
20
Agitation
24
19
25
20
Anxiety
13
10
23
18
Vomiting
6
5
20
16
Insomnia
11
9
19
15
Lightheadedness
10
8
18
14
Constipation
7
6
17
13
Accidental Injury
3
2
15
12
Diarrhea
11
9
15
12
Akathisia
3
2
14
11
Tremor
3
3
7
6

We can also conclude from the above study that placeboes are certainly powerful, which speaks to the power of the mind.
A second placebo-controlled study addressed aripiprazole in the treatment of acute manic or mixed episodes in patients with bipolar type I disorder with similar results [Sachs G, Sanchez R, Marcus R, Stock E, McQuade R, Carson W, Abou-Gharbia N, Impellizzeri C, Kaplita S, Rollin L, Iwamoto T, The Aripiprazole Study Group. (2005). Aripiprazole in the treatment of acute manic or mixed episodes in patients with bipolar I disorder: a 3-week placebo-controlled study. J. Psychopharmacology (Pre-print)]. This study excluded the same types of patients and started with 272 hospitalized patients. This time, 53% of subjects completed the three week study. Reasons for discontinuation were similar. The response rate to the drug was 39% by the end of the first week (compared to 27% with placebo) and 53% by the end of the third week (compared to 32% with placebo). Apparently most placebo responders, respond within the first week, while medication responders continue to accumulate after the first week. Drug treated patients did improve more than placebo treated patients on a number of measures, including the Clinical Global Inventory (CGI), the Young Mania Scale, and the Positive and Negative Symptom Scale, but not the Montgomery-Asburg Depression Scale.
Divalproex15 [Sachs G, Collins M. A placebo-controlled trial of divalproex sodium in acute bipolar depression. Paper presented at: 40th annual meeting of the American College of Neuropsychopharmacology.; December 9-13, 2001.] and other anticonvulsants are used as single agents in the treatment of mania, but have bot been shown as effective for bipolar depression with the exception of lamotrigine.1 An 8-week, multi-center study assigned 22 people to divalproex and 22 to placebo. At the study’s end, drug and placebo were similar in reducing depressive symptoms.
While the data for lamotrigine17 as a single agent for bipolar depression is convincing, many people are still left out in the cold. studying one study comparing low dose (50 mg/day), high dose (200 mg/day)and placebo with over 60 people in each group,18 [Calabrese JR. Bowden CI, Sachs GS. Ascher JA, Monaghan E, Rudd GD. A double-blind, placebo controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin. Psychiatry 1999; 60(2):79-88.] 44 to 50% of people taking lamotrigine improved compared to 36% of people taking placebo on the Hamilton Rating Scale for Depresson. On another rating scale – the Montgomery Asburg Depression Rating Scale, 50 to 54 % of people taking lamotrigine improved compared to 28 percent of people taking placebo, similar to what was seen on the Clinical Global Impressions Scale, on which 42-50 percent of people taking lamotrigine improved compared to 28% (again) taking placebo. The high percentage of non-responders and the high percentage of placebo responders again, suggests to me, that more alternatives are needed for treatment and that internal, environmental, and other poorly understand factors are subsumed under the heading of placebo. The presence of a placebo response shows that people improve despite medical treatment, and we should study these people to understand why.
A second study found lamotrigine to be equivalent to placebo in treating a mixed group of people with both bipolar I and II depressions. It was more effective than placebo only for people with bipolar I depression.19 [Bowden CL. Novel treatments for bipolar disorder. Expert Opinion Invetig Drugs 2001;10(4): 661-671.] In a third study, people with “treatment resistant, rapid-cycling” bipolar depression improved more with lamotrigine than with placebo.
Combining an antidepressant with an anticonvulsant is common for bipolar depression. A study of 27 people compared two anticonvulsants with an anticonvulsant plus an antidepressant (most commonly, an SSRI like Prozac). People tolerated the second combination better than the first, with a 0 percent drop-out rate compared to a 38 percent drop out rate for anticonvulsants alone. The effectiveness was similar with half the people unresponsive.
Lithium alone or with an anticonvulsant or with a third drug, an SSRI or a tricyclic antidepressant is another common combination.. [Nemeroff CB, Evans DL, Gyulai L. Double-blind, placebo-controlled comparisons of imipramine and paroxetine in the treatment of bipolar depression. Am J Psychiatry 2001; 158(6): 906-12.] In a study of paroxetine (Paxil)20, imipramine, or placebo with lithium, the highest response rate barely topped 50 percent.
Psychotherapy. Psychotherapy is effective with bipolar depression [Colom F, Vieta E. Psychological interventions in bipolar depression. In El Mallack RS, Ghaemi SN. (2006). Bipolar Depression: A comprehensive guide. Washington, DC: American Psychiatric Association Press, pp. 215-226.] though I would draw a distinction between psychotherapy and healing, which will be discussed under alternative therapies. My particular approach to healing with bipolar depression involves (in addition to medications or nutrients, either of which addresses the underlying mood instability) involves the use of narrative therapy, energy medicine, and spiritual healing. I find this much more effective than psychotherapy alone, which we all do, since, as Colom and Vieta point out, much of cognitive-behavior therapy is just plain common sense.
A number of conventional psychotherapeutic approaches have achieved statistical significance in randomized, controlled trials, including family focused interventions,[Miklowitz DJ, George EL, Richards AJ. (2003). A randomized study of family focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 60: 904-912.], training in prodromal identification [Perry A, Tarrier N, Morris R (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. Br Med J (418: 149-153.], cognitive-behavioral therapy [Lam DH, Watkins ER, Hayward P. (2003). A randomized, controlled study of cognitive therapy for relapse prevention for bipolar affective disorder. Outcome of the first year. Arch Gen Psychiatry 60: 145-152.], and psychoeducation [Colom F, Vieta E, Martinez-Aran A. (2003a). A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 60: 402-407; Colom F, Vieta E, Reinares M. (2003b). Psychoeducation efficacy in bipolar disorders beyond compliance enhancement. J Clin Psychiatry 4: 1101-1105.].In Canada, 85% of psychiatrists include psychotherapy in their management of bipolar disorder in addition to medications (Sharma V, Masmanian DS, Persad E. (1997). Treatment of bipolar depression: A survey of Canadian psychiatrists. Can J Psychiatry 42: 298-302.].
Alternative therapies.
Nutrient therapies. Several studies have demonstrated that psychiatric symptoms such as depression, mood swings, and aggression may be ameliorated by supplementation with broad-based nutrient formulas containing vitamins, minerals, and sometimes essential fatty acids. [Kaplan BJ, Fisher JE, Crawford SG, Field CJ, Kolb B. Improved mood and behavior during treatment with a mineral-vitamin supplement: an open-label case series of children. J Child Adolesc Psychopharmacol. 2004 Spring;14(1):115-22.]

Eleven patients were studied to determine the therapeutic benefit of a nutritional supplement (Empower Plus) for bipolar depression. The study consisted of 11 people with DSM-IV-diagnosed bipolar disorder who were aged 19 to 46 years and taking a mean of 2.7 psychotropic medications each at entry into the study. The supplement was a broad-based combination of chelated trace minerals and vitamins administered in high doses. At study entry and periodically thereafter, people’s symptoms were assessed with the Hamilton Rating Scale for Depression, the Brief Psychiatric Rating Scale (BPRS), and the Young Mania Rating Scale (YMRS). For those who completed the minimum 6-month open trial, symptom reduction ranged from 55% to 66% on the outcome measures. The need for psychotropic medications decreased by more than 50%. Benefit was shown on all the outcome measures with a reduction in the mean HAM-D score at entry from 19.0 to 5.4, in the BPRS mean score from 35.3 to 7.4, and in the YMRS mean score at entry from 15.1 to 6.0, all statistically significant. The effect size for the intervention was large (> .80) for each measure. The number of psychotropic medications decreased significantly. In some cases, the supplement replaced psychotropic medications and the patients remained well. The only reported side effect (i.e., nausea) was infrequent, minor, and transitory. [Kaplan BJ, Simpson JS, Ferre RC, Gorman CP, McMullen DM, Crawford SG. (2001). Effective mood stabilization with a chelated mineral supplement: an open-label trial in bipolar disorder. J Clin Psychiatry. Dec;62(12):936-44.]
A study of 11 children (7 boys and 4 girls) with mood and behavioral problems participated in an open-label trial of the role of a nutritional supplement (Empower Plus) in treating their symptoms. [Kaplan BJ, Fisher JE, Crawford SG, Field CJ, Kolb B. Improved mood and behavior during treatment with a mineral-vitamin supplement: an open-label case series of children. J Child Adolesc Psychopharmacol. 2004 Spring;14(1):115-22].Parents completed the Child Behavior Checklist (CBCL), Youth Outcome Questionnaire (YOQ), and theYoung Mania Rating Scale (YMRS) at entry and following at least 8 weeks of treatment. The YOQ and the YMRS improved significantly from the baseline to the final visit. Improvement was significant on seven of the eight CBCL scales, the YOQ, and the YMRS. The effect sizes for all the outcome measures were relatively large.

The biological narrative has even infiltrated the field of literary criticism as one would expect since we are all embedded in the same larger culture and share a common history, whether psychiatrists or English professors. In writing about Virginia Woolf's mood swings (which we are now calling bipolar disorder), Thomas Caramagno21 [Caramagno, Thomas. The flight of the mind: Virginia Woolf's art and manic-depressive illness. Berkeley: University of California Press, 1992] demonstrated the effect of the psychiatric narrative on literary criticism. He says, “[We must reconsider Virginia Woolf’s] fiction in light of recent medical discoveries about the genetic and biological nature of manic-depression—findings allied with drug therapies that today help nearly one million American manic-depressives live happier and more productive lives. In the real world of the clinic, treatments using lithium, anti-depressants, and anti-psychotics have revolutionized psychiatric care for mood swings and produced miracle remissions for cases that thirty years ago would have been considered hopeless. But in the rarefied atmosphere of literary academia, many critics still cling to the Freudian model of this disorder as a neurotic conflict that the patient is unwilling (either consciously or unconsciously) to resolve.”
Proponents of the biological story argue superiority over the previous Freudian story in that it describes people as unable to change instead of unwilling to change. What hasn’t changed is the assignation of the “problem” to the individual with an implicit judgment of inferiority. Freud’s movement stole “mental problems” from the Church as moral inferiority to create psychological inferiority. Biological psychiatry transforms this to genetic inferiority. Caramagno has characteristically little to say about non-responders and placebo responders.
The costs of conventional psychiatric treatment of bipolar disorder are large. A 1991 report from the National Institutes of Mental Health estimated total U.S. costs for bipolar illness at $45 billion annually. It is growing exponentially.
The construction of bipolar disorder as a biological-genetic disorder allows psychiatry to flourish. The accompanying idea that bipolar disorder can only be treated with medication allows the pharmacology industry to flourish. People diagnosed with bipolar disorder who subscribe to the biological story can relinquish all need to participate in any conversations except about which medications to take. Larger communities are excluded from dialogue except to educate family about “how to live with a mentally ill member,” as one class is described at the hospital where I work. If bipolar is entirely biological and is entirely treated biologically, then no value comes from conversations among affected parties except to educate them from the expert paradigm.
Gergen writes that “enormous problems inhere in distinctly psychological modes of explanation.”22 [Gergen KJ. Realities and Relationships: Soundings in Social Construction. Cambridge, MA: Harvard University Press, 1994, p. 276.] The same can be said for distinctly biological modes of explanation. We could say that privileged explanations are usually inadequate.
What do non-responders do within the biological narrative. Their lives are rarely studied. I have observed that they pursue a variety of courses, common ones included chronic alcohol and/or drug abuse as a self-medication strategy. Some use hidden talents and resources to excel in communities were their mood swings become attractive eccentricities. The stereotype of the leading lady of the 1940’s had this kind of moodiness. Some pursue other types of healing, spontaneously loose their bipolarity, die, become soldiers, have spiritual transformations, and otherwise remain hidden from the dominant discourse. I want to tell several of their stories in the next section.
I have tried to find references to what could be considered bipolar like symptoms in writings about post-Columbus indigenous people, only to have failed. The closest I have come is to the visionary healer or spiritual leader and the fabled warrior. Descriptions exist of those who have had days of ecstatic visions only to collapse and sleep for days. This behavior was honored and supported. If it was “manic” or “psychotic”, the person was protected during the ecstasy since the visions were expected to be portentous, of great importance to the tribal group. When spirit left the person, as these descriptions commonly report, and the person collapsed, the community was present to nurse them back to health. If this was bipolar disorder, it had a completely different meaning and context in tribal society.
Perhaps the tendency of indigenous cultures to see problems in terms of whole communities and not individuals renders the bipolar label unintelligible. Perhaps bipolar requires reduction to individualism in order to appear or to exist. Within traditional communities, I suspect that affect is regulated differently than among members of modern Euro-American culture. When people live tribally, women menstruate at the same time, and probably other biological cycles synchronize. I suspect that the community modulates affect and provides regulation when the individual is unable to do so. Biological psychiatry’s genetic drift hypothesis states that the more severe bipolar people would be isolated and alone, since they are too bizarre to maintain normal social relations. Of course, they would say this from their individualistic, biological story. An indigenous explanation might reverse this and say that isolation and loneliness without community is harmful.
People’s Alternative Stories
Mary, like many people who have acquired the bipolar label, was fascinating. She was articulate, talkative, intelligent, and suffering. I begin by asking people to tell their story. Inevitably the story revolves around what they think is wrong with them. Mary thought bipolar was wrong with her. Almost always the story focuses on a defect within the person.
Mary constructed lives and destroyed them on a regular basis. Each life lasted about 3 years. A life would entail a new job, new relationship, new location—everything new. As time passed and frustration mounted, a threshold was reached in which Mary would quit her job, end her relationship, move—change everything. Often these tumultuous periods were associated with hospitalizations. During these periods of change, she would forget to sleep, eat, or rest. She would receive divine inspiration that would launch her new life. In the hospital, she would be calmed with medication, which she would gradually eliminate.
Mary wanted to focus upon her incredible visions and insights. I was more interested in the moments before she lost control. She described these moments as resembling Alice standing before the mirror, deciding whether or not to walk through. Mary recounted that walking through meant that she was gone. It meant complete commitment to upheaval. I suspected that we had a chance to address that moment of decision making, the moment before she decided to walk through the mirror.
Mary taught me how repetition can bring forth transformation. I asked her to watch The Wizard of Oz everyday for one month. She lived some distance away and could only come once monthly. She wondered why. I answered that I suspected that she and Dorothy had the same dilemma, and that she could learn from Dorothy’s choices and mistakes. Mary accepted this explanation and resolved to watch the movie.
When Mary returned, she reported a transformation. She had realized how wasteful and destructive her actions had been, that she hadn’t really needed to overthrow her life so frequently. She had realized this from watching Dorothy night after night. I could have walked away from the wicked witch, she said, clicked my heels, and stayed in Kansas after all. I didn’t need to go find the wicked witch of the West or struggle with the wizard on his terms. I could have just done something else.
Then we focused on compassionate self-acceptance—the idea that we are here today as a historical creation of all that has come before, that Mary’s past struggles, even her hospitalizations, had contributed to making her the awesome person that she was today.
Mary has stabilized without medication. She has broken her three-year habit and is in her fifth year, now, of work within the same field, with the same boyfriend, without upheaval. She watches Dorothy periodically and continues her daily practice of aikido. She credits this practice and The Wizard of Oz, with changing her life.
*********
Betty Running Bear came to see me in the heights of medications despair. She had been prescribed so many different medications for her bipolar disorder, that it was confusing. She took Thorazine, Lithium, Haldol, Depakote, Prozac, and Klonopin. I wondered how anyone could get so many drugs. Betty was half-Cherokee; half-African in origin. That weekend a yuwipi ceremony was scheduled with a local Native healer from the nearby reservation. Yuwipi means “they tie him up” in Lakota. The ceremony was given to Horn Chips in a vision on the top of Bear Butte (South Dakota) in 1868. It’s purpose was to cure “white people disease.”
In the yuwipi ceremony, a ceremonial space is created in the center of an empty room. A rug is laid upon the floor, covered by a star quilt. Number 10 tin cans are placed at each corner holding enough earth to support a stick carrying a flag for each of the four directions (yellow, red, white, and black). Strung like the ropes of a boxing ring are 405 prayer ties – small pieces of fabric in which tobacco is placed, tied upon a cotton string. The windows of the room and the doors are covered with black plastic until no light can be seen. The ceremony begins with the healer’s hands being tied behind his back, then together, then his arms are tied, and then he is wrapped in a star quilt which is tied around him. When he is completely tied up, the lights go out, the singing and drumming begins, and somehow, sometime during the darkness, the spirits untie him. When the lights go on and he is revealed to be untied, the healing of the sick commences. Lakota people joke that the ceremony must have worked because smallpox has vanished.
Betty presented herself to be healed in the yuwipi ceremony, and the medicine man took her home. He recognized her suffering and had her move in with his sister whose husband had just died. Perhaps he recognized that Betty’s pressured loquaciousness would offset the silent loneliness of a bereaving widow. Being a client of the mental health system, Betty had no where better to go. She lived in a group home in which the major activity was television watching. Connectedness among residents was minimal. She stayed.
The moment Betty moved in, she became part of a large extended kinship network in which life could be completely contained. Between healing ceremonies, family obligations, and social activities, Betty needed no planning for any aspect of her life. She did help the sister with her household activities and was an avid cleaner, which was appreciated in that family. Like a schizophrenic who was taken in by Melvin Grey Fox in Coyote Healing, Betty became another family member. Her life was regulated. One year later, she was on half the medication she had used previously. Two years later it had been reduced to about a fourth. Four years later she was off medication.
An alternate story for healing had been substituted for psychiatry’s biological narrative. In this story, embeddedness in community and participation in ceremony regulates mood quite effectively. The participants in this story would not even be able to enunciate it, for it is their life. Now a member of the medicine man’s family, Betty’s life revolved around ceremony, social obligations, reciprocal family relationships, and service to others. She had learned skills for self-soothing – notably ceremony and ritual, all of which serve to induce the kind of trance state found in hypnosis or meditation. The physical work of housecleaning, cooking for post-ceremony feasts, and the comraderie of Native American women, transformed Betty’s life experience. When life experience changes, I argue, so does genetic expression and physiology. What a different story from the medication for life narrative.
*************
Lauren came with a diagnosis of bipolar II disorder, currently depressed. Her mood alternated between being depressed and feeling mildly euphoric (what some people would call happy). Lauren had been participating in the medication story for more than 15 of her 45 years, but was becoming increasingly unhappy with the side effects of the drugs. She was taking Prozac, Zyprexa, and Depakote, though she had already started to reduce doses on her own.
I worked with Lauren, along with Will (an osteopathic physician) and Amy (a yoga teacher). My perspective with Laura was that other daily practices need to replace the daily practice of taking pills. Yoga is an effective daily practice. My colleague, Amy Weintraub23 has written about yoga for depression and has reviewed its positive benefits. I offered Laura the Chinese point of view that you couldn’t very well evaluate something’s benefit to you until you have done it 100 consecutive days.
Lauren came to us from Louisiana with plans to stay for 10 days. Each day would focus on skill-building, her learning practices (tools) to take home with her and use on a daily basis. We had collectively decided that her tools would be yoga, ceremony, and visualization. Will would help this process along through facilitating structural change in the body (craniosacral therapy, neuro-muscular realignment, and whatever else emerged as potentially useful). I would teach visualization and ceremony.
I began by suggesting we banish the “bipolar word,” as I often do. I suggested we enter into an altered state of consciousness and let “what we were dealing with” define itself. Laura agreed and I began to lead her through (and teach her) meditation/visualization techniques. I begin with focusing on breathing and mindfulness of the present moment and lead into relaxing more and more and letting go of thoughts and preconceptions. After about 15 minutes of this, I suggested that the things that had brought her to me could organize themselves into their own entity. In the dreamtime (trance, altered state, etc.) they could even take form and shape. That form and shape could have a voice and the voice could communicate.
The ensemble of everything tied to the bipolar label, and probably other things, too, began to coalesce into a shape of a character who called himself “Take It Easy.” I double checked for gender, and he was definitely male.
I gave suggestions to go backward on the river of time, using Lauren’s desired mode of river travel—steam, raft, canoe, powerboat, whatever—until the driver of her craft landed her at the place in the stream of time in which “Take It Easy” had been conceived. We journeyed backward by seven generations to Lauren’s ancestral home in Scotland. Images arose of children being beaten to conform. The Scoth Protestant ethic was to “beat it out of them.” A story emerged of the many generations for whom “taking it easy” meant conforming, stuffing originality, protest, opposition, and other undesirable traits. Overthrowing “Take It Easy” meant rebelling against self-criticism for the perspective from which the criticism could be made was a family culture of conformity which didn’t match the story Laura wanted to tell about herself. She wanted to be more outlandish, more outspoken, even flamboyant. Being hypomanic allowed her to flirt with these qualities, but always in a way in which she could feel shame later and be criticized.
We developed a series of practices to use to oppose self-deprecation. These included the daily yoga, daily ceremony, and daily meditation. My theme for her was, “It’s all good. It’s all fine. You don’t have to change. In fact, don’t do anything.” This was a recipe against the self-critical perspective.
~~~~~~~~~~~~~~~~~~~
Mary had found a healing temple to join for community. Laura was encouraged to gather together everyone she knew who was interested in healing and to meet on a weekly basis to form a healing community. She has done this and it has been an important part of her maintaining her harmony and balance.
This is in stark contrast to the SMI (seriously mentally ill) clients who populate the mental health care system and who remain isolated without support, despite their plethora of medications.
In these three stories, people have broken free from the biological psychiatric narrative. They spend no money on drugs. Their daily “meds” include yoga, meditation, prayer, all embedded within community. They have alternate stories which would be unnoticed by the dominant paradigm. If noticed these stories would be dismissed as “quacky,” so rare as to be unimportant and ungeneralizable to any significant number of people, or evidence of misdiagnosis (since bipolar disorder is, by definition, life-long).

These stories represent an “underbelly” of American psychiatry, but perhaps also a repository of potential transformation, and help for the 50 percent of non-responders – an alternative that has other solutions in addition to medication or besides medication, as the case warrants. This solution would perplex modern psychiatry, for it is post-modern. Each individual has his or her own path to less suffering. The solution comes develops from the affected community and not the professional expert.

[*] Mania is operationally defined in the DSM-IV-TR in terms such as grandiosity, hyper-religiosity, lack of need for sleep, boundless energy, excessive spending, suspension of good judgment over the consequences of one’s actions, loquaciousness, inability to stop a behavior once started, and an inability to modify one’s plans based on feedback from the environment. Hypomania is defined more as persistent irritability or mild euphoria—in other words, a lessened and harder to recognize form of mania that oscillates with periods of depression. Both types of bipolar patients spend more time being depressed than high or irritable.
[1] American Psychiatric Association. Practice Guidelines for the treatment of patients with bipolar disorder (revision), Available at www.psych.org/psych_pract/treatg/pg/prac_guide.cfm. Accessed August 12, 2004.
[2] Literature in the Reader: Affective Stylistics, Stanley Fish, New Literary History, Vol. 2, No. 1, A Symposium on Literary History (Autumn, 1970) , pp. 123-162
[3] Interpretation of Cultures, Clifford Geertz, New York: Basic Books, 2000.
[4] Fanthum E, Rummel E. The Collected Works of Erasmus. Toronto: University of Toronto Press, 1989
[5] Hall M, Ratner C, Riebner R. The Collected Works of L.S. Vygotsky, Volume 5. Child Psychology. Boston: Kluwer Academic/Plenum Publishing, 1999
[6] Vygotsky, op. cit., pp 169-174
[7] Zrehen S, Kitano H, Fujito M. Learning in Psychologically Plausible Conditions: The Case of the Pet Robot. In Pfeiffer, Blumberg, Meyer, Wilson. From Animals to Animats 5: Proceedings of the Fifth International Conference on Simulation of Adaptive Behavior. Cambridge, MA: MIT Press, 1998
[8] Champandard A. AI Game Development: Synthetic Creatures with Learning and Reactive Behavior. New York: New Riders, 2003.
[9] Williams M. Wittgenstein, Mind, and Meaning: Towards a Social Conception of Mind. New York: Routledge, 2002, pp. 265-274.
[10] Burns WD, Klawunn W. The Web of Caring: An approach to accountability in alcohol policy. http://phoenix.edc.org/hec/pubs/theorybook/burns.pdf, Last accessed 19 July 2006.