Sara K. Schneider's Skin in the Game

Reflections on body, culture, and spiritual practice

A Re-membering Human

Sometimes I look to their bodies for a definitive answer to my ongoing prayer for understanding. I remember how I felt when I touched my grandfather’s scars, those deep imprints left by Cuba: I was a blind child reading the past in Braille, understanding for the first time the vast plantation, the raging river, the cattle, the dark jail, the soldier’s clubs. When I ask my patients to undress, I think of him. … Funny how I never feel [their] pain, though I can often reproduce it in them as I press and poke the indicated region. Pain must be too personal, held too deeply with the body, to be known without actually experiencing it. Though my grandfather’s smile emphasized a certain scar on his forehead, and therefore could feel like a blow to the head, so bitter and full of loss, I never felt the pain he must have known. I can only imagine it.

–Rafael Campo, The Poetry of Healing: A Doctor’s Education in Empathy, Identity, and Desire

Twenty-five years of virtually constant computer use: what do you expect? (Hint: If you’re thinking of something between the fingers and the forearms, you’re getting very, very warm.)

To give them credit, the office staff had mentioned that the diagnostic procedure might be “a little uncomfortable,” but nothing more than the slight shock to the system than one might expect from acupuncture needles. The NCV/EMG test would help us find out whether my carpal tunnel syndrome (so much for the pride of being an early adopter!) had involved any nerves in the neck. “More data”: I’m on board!

For the first portion of this test, the physician sets electrodes along the arms, chest, and neck and administers electric shocks; she wants to time the velocity by which the electric signal is conveyed along the nerve. In the second part, the examiner inserts needles into the muscles, asks the patient to contract her arm, and again tests conduction speed (of the pain impulse!). All I can say is, the speed of the pain impulse was something I understood a whole lot better through experience.

I was lying on the examining table when a white female physician and the medical resident who was shadowing her entered the testing room, the former brusquely and if she were determined not to waste a single motion. I wondered whether the force with which she moved didn’t include some overkill. I noticed my new doctor’s almost aggressive efficiency as she set up her equipment and slapped electrodes onto my chest, neck, and arms. Scarcely speaking to me, she instead directed her words to the medical resident, who I guessed was from South Asia. The language was technical, dealing (I think) with how to read the metrics they were about to extract from my body. The resident’s movement contrasted deeply with the doctor’s: she moved in a more spacious, diffuse way, as if uneasy of her place in the triangulated encounter.

When it came time to test my upper body nerves (so to speak), the doctor applied the shocks at different points as if searching for a stud behind drywall. I was astounded by how quickly I experienced what seemed a projection of inanimacy upon me. My new physician was testing my body as if my self had already left it. I hoped that happenstance was still years off but had to reckon with a moment of uncertainty as to whether I was perhaps the person or the state of consciousness she touched me to be. Fighting my own reactivity, I thought I would try some temperate inquiry, ultimately to try to learn not why the tests were being done, but why she was doing them in such a depersonalizing way.

Do you do these tests every day? I asked her. Pausing and staring past me for an instant, she replied, no, only on one day each week, on Wednesdays. Experience had taught her she couldn’t handle on a daily basis the volume of patient venom that would be directed at her during these tests; one man had even jumped off the table and fled the office, electrodes still on, for good. She offered that it worked better for patients if she administered the shocks quickly, as that would minimize the length of time patients had to experience pain.

Her pain or the patient’s? I wondered. The nerve conduction velocity test was physically arduous; after all, the point of the test is to cause and then study nerve pain! But the physical challenge of the test, I soon realized, was a relatively minor part of what I was feeling on the table, which largely derived from experiencing being touched as if I were not alive.

She didn’t “play me like a violin,” at least not in the seamless melding between player and instrument played, or the kind of unity experienced by the dancer who is also danced. Instead, she played me, as the Italian composers might have said, bruscamente: brusquely, abruptly. Dolores Krieger, the inventor of a bodywork modality called Therapeutic Touch, urges therapists to remember that, as humans, “we don’t stop at our skin.” The brutality of the touch had little to do with its mechanics, much more with with what led to each prick and shock and how that intention sank in.

Physician-author Danielle Ofri writes of the “singular intimacies” between physician and patient, a connection that, though not a romantic one, “is an intimacy nevertheless.” But what of professional boundaries? Aren’t caregivers–particularly those with doctoral degrees–supposed to maintain an appropriate level of professional distance? As the progenitor of bioenergetics, a body-based psychotherapy, Alexander Lowen actually urges that professionals learn how to touch patients as part of both diagnostic and healing processes. I’ve substituted “professional” for “therapist” in sharing Lowen’s thoughts: “A professional’s touch,” he writes, “has to be warm, friendly, dependable and free of any personal interest to inspire confidence in touching. … One should expect a professional to know the quality of a touch, to recognize the difference between a sensual touch and a supportive one, between a firm touch and a hard one, and between touching that is mechanical and that which has feeling.” But the touch has to be with “clean hands”: free of the provider’s own need-seeking.

As a culture, we tend to give greater emphasis to outward transgressions of touch boundaries with vulnerable populations–violations of children’s sexual integrity by some clergy, the potential for sexual exploitation of students by teachers or college faculty–than we do to the opportunities for healing that are lost to professionals’ unwillingness to examine how their own needs may inhibit healing. The withdrawal or withholding of a touch that had an opportunity to heal can also be traumatizing.

Some argue that it is in the very nature of Western medical training to objectify the patient in order simply to be able to handle the constant onslaught of human suffering a professional faces every day, that the desensitization is a unavoidable and concomitant in the work. But how encompassing must this be to allow the health-care worker to provide healing to the patient before her and to maintain her own sanctity and integrity to serve future patients well?

Practitioners in many fields–teaching and spiritual guidance come to mind as readily as does health-care–might consider trying the practice following, allowing you to consider the healing power of your own professional touch–given, misgiven, and withheld.

How have you experienced the “singular intimacies” of the care given you by health-care, spiritual, or educational professionals? How have you known when and whether their touch, given or withheld, has helped or harmed you?

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing | Leave a comment

A Practice on Professional Touch

I once asked a massage therapist if she’d ever had a client she was loath to touch. Only one, she replied, in all the years she’d been giving massages. Though she had a hard time pinning down just what about the client had provoked her aversion, she experienced something about him as “evil.” She struggled through the massage, but required several days to recover and clear.

In this practice, you’ll pay attention to your reactivity to the people with whom you must engage in your professional life, especially those for whom you carry some professional responsibility for the well-being of their minds, bodies, and spirits.

Investigate:

  • To whom do you notice you want to get closer? With whom do you have some inchoate aversion?
  • How would you label what in them is “making” you react in the way you are? Is it something about their physical person? Is it something harder to define, something in their “energy,” whatever that may mean? How close can you get to labeling it?

Now, turn your attention to yourself:

  • How are you experiencing your desire to reach out to them, to offer them healing touch, acknowledging that it is not just they but you too who have a body? Why do you want either to touch them or not to?
  • What would happen if you thoughtfully, respectfully envisioned doing the opposite of your initial inclination –touching them compassionately if your inclination is to avoid, keeping at a mindful distance if you’re drawn to connect?
  • What might be impact on them, on you, of making this different choice–an impact that stems more from the how of what you do than from the what?

What did you find out?

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing, Insight Practices | Leave a comment

Anne Fadiman’s The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures

The Spirit Catches You and You Fall Down

Although not a new book, Anne Fadiman’s The Spirit Catches You and You Fall Down (1997) classically highlights a life-and-death crisis that devolves from Western medical professionals’ living out an ethnocentric self-assurance and a hermetic professional worldview. Fadiman became intrigued by what she’d heard about the clash between the Western medical establishment of Merced, California and the concentrated group of Hmong refugees from Laos who had begun settling there in the 1970s, escaping persecution by the Vietnamese after their little-known contribution as guerrillas to the American cause.

The Hmong were involuntary migrants, not given to adopting American ways any more than necessary to survive. Some feared going to doctors whom they thought might rather study them than help them. To the Hmong, Western doctors engaged in hazardous practices. They extracted large volumes of blood from their patients. They opened the body in surgery and in autopsies, and inevitably and irreparably damaged the integrity of the person, not only for this lifetime but for future incarnations. They announced the probability of death. The Hmong mistrusted Western medications and took fractions of what had been prescribed, putting the physicians in the untenable position of trying to “game” how much they might have to prescribe to end up with a Hmong patient’s actually ending up taking the desired dose.

Fadiman began fieldwork with a particular Hmong family, whose six-year-old daughter Lia had been in and out of the Western medical machine since she was a baby because of her epileptic seizures. She inquired equally into the perspectives of the entourage of doctors who treated her and who attempted, to varying degrees, to communicate effectively with her parents.

Lia’s parents fundamentally disagreed with the doctors about the origin of Lia’s problem and about the impact of the medications that had been prescribed for her. To Lia’s parents, the troubles began when her soul was frightened out of her body when her sister slammed a door, and her seizures would be instigated by a spirit “catching” her. The cure would be perhaps a very short course of medicines, but ultimately would be carried by Hmong shamanism, animal sacrifices, and herbs.

Fadiman’s book sides neither with the native medical cosmology of the Hmong nor with the self-justifying medical culture of the West, situating Lia’s tragic decline in the very gaps between the two. If there was any fault, it lay in the failure of the Western physicians to give credence to the Hmong worldview or to incorporate it into a realistic treatment plan. Fadiman writes of the caricature–just an extreme of the actual–of the M.D., who is an “all-head-no-heart formalist who, when presented with a problem, would rather medicate it, scan it, suture it, splint it, excise it, anesthetize it, or autopsy it than communicate with it.”

While Fadiman concludes that “American medicine had both preserved [Lia’s] life and compromised it,” she wonders whether saving the body, as much of Western medicine is geared to do, or preserving the soul, as was part of the Hmong concern, could not both be considered.

Reading The Spirit Catches You and You Fall Down, I am reminded of the lyrics of “Walking in Space” from the rock musical Hair. Set against the backdrop of the Vietnam War–which the Hmong referred to as the American War–the song extols the visions possible under hallucinogenics:

In this dive
We rediscover sensation
In this dive
We rediscover sensation

Walking in space
We find the purpose of peace
The beauty of life
You can no longer hide

Our eyes are open
Our eyes are open
Our eyes are open
Our eyes are open
Wide wide wide!

It’s not that the singers saw nothing taking the hallucinogenics. The irony of the song is that they thought they saw everything–while only seeing some thing.

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Body Culture in the U.S., Books, Health, Medical Practice, and Healing | Leave a comment

Clinical Empathy in Extremis

As has long been known in the field of undercover law enforcement, some information is easier to gather secretly than overtly.

In late 2008, three psychiatric nurses had themselves admitted as “pseudopatients” to a Dutch psychiatric hospital. In collaboration with an acting coach and a psychotherapist, they developed fictive biographies for their characters–“back stories”–much as do undercover cops. One of the players was admitted to the psychiatric hospital by his “brother” after a suicide attempt that was part of his back story; a history of aggressiveness was also part of his backstopping. Family members, played by professional actors, came to visit them while they lived in the psychiatric hospital as a patient would. Following the lead of a famous covert investigation of the patient experience by David Rosenhan in 1973–“Being Sane in Insane Places”–these undercover investigators were trying to understand the conditions under which psychiatric patients experience their illnesses.

Medical student Kristen Murphy living in a nursing home.

Medical student Kristen Murphy living in a nursing home.

Understanding the patient experience from the inside has become part of some medical schools’ training programs. The University of New England medical school sent (young) medical students in geriatrics for two-week stints as “patients” in regional nursing homes where they could experience the anomie, the longing for human contact, and the challenge of navigating often insensitively designed environments: what their patients live every day. While it was of course impossible to be in any way in deep cover at 50 years younger than the target population, there was still much for participant-observers to learn. Shower bars, for example, were too high for people in wheelchairs.

How far does a doctor have to go in feeling or experience to treat her patient effectively? And, practically, how close can a doctor get to experiencing what her patient feels without running the risk of being sucked into the morass of the patient’s suffering? Isn’t there also a peril of projecting her own experience of suffering upon her patient and blinding herself to the suffering that is truly the patient’s own?

All this is at the middle of an ongoing debate in medical practice and training–at least in the places where patient experience is considered part of the clinical picture. Some say, just recognizing, identifying, being able to label the experience the patient is “presenting” is enough to treat an illness well. Others demand that, in addition to the awareness of the patient’s state, the health-care provider’s being able to respond in the moment, with real emotional savvy, is what constitutes true clinical empathy. They posit that, not only are so-called clinical outcomes better when doctors and nurses experience and convey clinical empathy, but their own satisfaction in their work rises when they allow themselves to be moved by patients.

Some concerned with these issues have been using theatre training to improve physicians’ observational and receptive skills, helping them to listen for subtext, values, and strengths, and their performance skills, coaching them to express themselves fully and clearly through their voices and bodies and to use eye contact, breathing rhythms, and body positions to foster rapport with their patients. They distinguish between a surface-level and a “deep” acting, in which these skills have been internalized and become more automatic.

Yet the bodies of others are not only relational and physical, they are also cultural, and there’s evidence that physicians who fold all these elements into a treatment plan see better outcomes. Just as in On Killing, the book featured in Skin in the Game’s January issue that examines the conditions that make it easier for soldiers to kill, it is harder for doctors to feel empathy for those whom they perceive as being different from themselves-whose bodies and selves they perceive as “other.” The next phase of development in the humanization of the medical professions so that they become professions of healing is the encompassing of how the perspective of someone one may initially perceive as foreign, other–and, thus, inevitably “less than”–can transform into a collaborative relationship of inquiry, with two body-selves linked in a common humanity.

The Bodies of “Others”: Compassionate Care in the Health Professions will be presented at the American Holistic Nurses Association conference June 3 in Colorado Springs. Please contact Sara to schedule this workshop for your health-care organization.

To subscribe to Skin in the Game’s monthly newsletter, send an email with “subscribe” in the subject line to sks@thinkingdr.com. To view past issues, click here.

April 30, 2010 Posted by | Health, Medical Practice, and Healing | Leave a comment

The Beauty of Altered Perfections: Living Into Disability

Looking at people in the street you will … be amazed at how many people show considerable variation from a neutral body. By observing them and analysing body part by body part, you can reconstruct their body with yours and feel what it is like to live in that state.
~ John Martin

I breathed the air of so many places without keeping a sample of any. In the end, everyone is aware of this: nobody keeps any of what he has, and life is only a borrowing of bones.

~ Pablo Neruda

My friend David recently attended a Sunday evening church service at a predominantly African-American church on Chicago’s South Side. Hand waving, dancing, singing were only a sampling of the forms that bodily and vocal participation took there.

That preacher inspired one congregant to activate her electric wheelchair and whiz up and down the church aisles as she warmed up to the night’s message. Nothing stopped this worshipper from using everything she had. Who knows what others experienced as they witnessed this unusual expression of fervor?

In their duet She Without Arm, He Without Leg: Hand in Hand, Chinese performers Ma Li and Zhai Xiaowei make moving use of their unique body capabilities. In their first contact, her gaze travels from the bottom of his crutch all the way up to his eyes; it is the crutch she sees first. Later, Ma Li curves into the crutch that Zhai Xiaowei uses to balance his weight, given that he is working off of one leg. He supports her with both arms around her waist, as her one remaining arm wraps around his neck.

You might be glad you clicked on the five-minute video of She Without Arm, He Without Leg (and then come on back!). Ma Li and Zhai Xiaowei’s technique is virtuosic, a jaw-dropping display of the extended capabilities of bodies that had to create workarounds. The refined beauty of their choreography often derives both from the shapes the bodies make in space and the power to inspire of these two athletes–he a former Special Olympics cyclist, she a ballerina–who overcame their grief over lost movement options to invent others.

Perhaps the most stirring effect stems from the dancers’ presentation of expanded possibilities for partnering. Ordinary partnering allows dancers to become taller (as one dancer lifts another), to do spins in quantity (as one dancer supports the waist or hand of the other), or to achieve positions that take an interplay between two bodies for balance. Yet in She Without Arm, He Without Leg, the partnering takes on a heartbreakingly tender quality as each dancer compensates for the limited movement range of the other.

Just as the extraordinary able-bodied athletes we watch compete in the Winter Olympics in Vancouver this month expand our notions of the bodily possible, the adaptations those with disabilities create point the way toward the unconceived-of potentials of the body–possibilities we can’t even conceive of until ingenuity and necessity show them to us.

Over the past couple of decades, dance companies have developed choreography for dancers with paraplegia, cerebral palsy, and other disabilities, partnering them with each other or with able-bodied dancers. In one such dance, two men partner each other, the one without legs spinning around and horning around and under his able-bodied partner.

As a member of the Heidi Latsky Dance Company producing The Gimp Project explains, people want to look at people with disabilities, despite a certain shame in doing so. TGP’s producer, Jeremy Alliger, says that this form of dance alters spectators’ very notions of what constitutes dance and dancing–and who gets to be considered a dancer. So does the explicit emphasis of this dance on the sexuality and sensuality of those with disabilities.

In his award-winning Waking: A Memoir of Trauma and Transcendence, Matthew Sanford, who has been paraplegic since the age of 13, traces his development as a yogi and teacher of those with disabilities into greater body-mind awareness. Through the change in his circumstances Sanford came to recognize that those with apparent disabilities are not a specialized population different in kind from so-called normals: “We all live on a continuum of abilities and disabilities,” he says. “As a paraplegic, I can no longer rely on the normal course of my daily life to ensure a healthy connection between my mind and my body. The same is true for all of us.”

As he rehabilitated his body without the ability to move his legs, Sanford learned to use his arms in “double time.” His path eventually took him to the practice of hatha yoga. He has evolved into a remarkable teacher of yoga students, especially those with disabilities–able to talk them, in the detailed style characteristic of the hatha yoga style, through the sensations that he cannot feel physically, but nevertheless experiences at an energetic level. For Sanford, working with disabled yoga students has shown him that the “principles of yoga are nondiscriminating–they can travel through any body.”

If “difference” is the source of the particular way one moves, how might the motion of a depressed body look, or display to the gaze and being of an onlooker? How does the gait of someone with sciatic pain or irrepressible physical energy appear, and what does it convey or share to those who are in nearby bodies?

As we watch and experience with another–even one whose bodily capabilities and expressions we find foreign–we may feel a kinesthetic empathy, a movement in our bodies that seems to correspond to the energetic effort and experience of others. It may be what we feel watching the ballet of the woman with one arm and the man with one leg, or it could be what Matthew Sanford “feels” when coaching a yoga student who has the use of his legs.

That kinesthetic empathy is the surge in us as we watch a parent run to pull a straying child out of the street, the tightness in our own chests as we watch an elderly neighbor make the effort to shovel heavy snow. It is body to body, and is perhaps compassion’s essence–one person’s being mirroring, even within, what he perceives the other’s experience to be.

Perhaps more difficult than to experience the pain or bodily limitation of another is to fully experience one’s own. But could this be a root of compassion? As Sanford pungently comments about the power of facing one’s own bodily limitation, “I have never seen anyone truly become more aware of his or her body without also becoming more compassionate.”

I’m curious: what have you seen or experienced in the Special Olympics?

March 30, 2010 Posted by | Body Culture in the U.S., Health, Medical Practice, and Healing, Physical Culture | Leave a comment

Body-lying

They say that the body doesn’t, or can’t, lie. I’m not sure I agree–at least as regards its meanings or intentions in social interactions.

A skilled body can misrepresent a state of mind, misdirect an interlocutor, or dissimulate felt emotion. Even a desensitized body can lie. Many times, as I debrief a party with a close friend on the way out, he’ll say, “You were having a great time in there.” I wheel around: as an introvert, I rarely enjoy large parties or formal gatherings. I am taken aback, not only because my friend can’t read me, but because my body, on automatic, contravened my boredom, irritation, or desire to escape.

Whether or not you have known bodies to lie, it seems entirely possible to lie socially about the body. For example, the Los Angeles Times reported more than a third of patients lie to their doctors about their health habits,  resulting in some dangerous clinical decisions (http://articles.latimes.com/2009/jun/08/health/he-lying8). Patients misrepresent their health, their lifestyles, or how they’re complying with doctor’s orders, concerned about the doctors’ judgment, invasions of their privacy, and potential conflict over the proper course of treatment to take–not to mention making disclosures that could affect their ability to obtain health insurance.

Of course, doctors sometimes lie about patients’ bodies, too, as when they elect not to tell a patient he has a potentially life-threatening diagnosis, so as not to have to deal with the range of emotions that could come up in the patient–or in themselves. In the clinical encounter, where a professional takes responsibility for the care of the body-mind of another, perhaps the most significant body fib in the doctor’s office is one of omission–that the doctor’s body is not an integral part of the story of the doctor-patient encounter. The qualities associated with the doctor’s own embodiment, her very way of manifesting her presence with the patient–using as barometer her own visceral responses to, and intuition about, the patient’s condition and his underlying concerns–are at the heart of the clinical encounter.

Even if–and perhaps especially if–her body can lie.

November 19, 2009 Posted by | Health, Medical Practice, and Healing, Physical Culture, Spiritual Practice | Leave a comment