Amitha Kalaichandran
Amitha Kalaichandran
(originally published on Medium.com)
Shiva Performing the Dance of Bliss while Vishnu and Brahma Provide Musical Accompaniment (or...a depiction of mirrors/teachers/expanders!)
More:
Original public domain image from Los Angeles County Museum of Art
I don’t often (or ever!) write about spiritual elements of health and healing (not to mention ideas with no references or ‘reporting’ per se!) but one concept resonated with me recently, after someone sent me a viral Tiktok video (!). The second point made — about mirrors/teachers/expanders seems relevant for life on and off social media, as well workplaces/companies because they are comprised of *people.* It’s a helpful framework to ‘reframe’ interactions with a growth mindset as well, and understand it all as a ‘dance’ we consciously participate in (or decide not to). However there aren’t any clear definitions, so this is my attempt here, as it seems to have resonated with close friends and loved ones, so it might be of interest to readers here, especially as it suggests an intersection between psychology and spirituality.
Of note, random passer-bys etc aren’t ‘relationships’ by definition, so those don’t really count in terms of our personal evolution unless there’s some kind of conflict or interaction that triggers us in some way to engage (it’s also a reminder that engaging ‘creates’ an energetic bond, which means energy, time, etc — why the most compassionate/conscious thing is not to engage).
Alright here we go. Relationships (friendships, family, coworkers, partners) fall into three categories:
1)Mirrors, 2)Teachers 3)Expanders
1)Mirrors
People that mirror parts of us we prefer not to confront. These deal with core wounds from childhood or early adulthood. Things like: needing to be perfect and moral (in order to be worthy/loved/feel secure and grounded and not anxious or abandoned), needing to please everyone and ‘be nice’ (in order to be worthy/loved etc), needing to fight/push for things (in order to secure resources/help/survive etc — this leads to envy and scarcity mindset)
(a) mirrors can have ‘good intentions’ for us ('helpful mirrors' or 'expansive mirrors')
…even if they bring up core wounds (unintentionally), the relationship helps us heal those wounds namely because the ‘mirror’ (other person) has the intention of kindness, compassion, patience, love etc (in other words: good intentions). This intention has nothing to do with us, but everything to do with how ‘healed and self-aware’ they are of their own triggers.
How can we sense their intention? How energized, at peace, relaxed, etc we feel around them *even if* parts of us feel triggered *at times*. Leaning into this allows ‘mirrors’ to transition into teachers and even expanders.
(b) mirrors can have ‘bad intentions’ for us ('harmful mirrors' or 'constricting mirrors')
…and they trigger our core wounds intentionally because their own core wounds dominate their actions and thoughts about others. They may take actions (overtly or covertly) to sabotage, harm, etc. An example might be a mirror with a core wound involving scarcity — this manifests as envy. They may be envious about someone’s job/income, apartment/house, partner/friend, kids, life stage, appearance/looks, etc. They may then sabotage the person they are envious of through gossip, overt or covert actions (including comments), energetic ways (“they don’t deserve this/them/etc — I hope they lose it.’) because they believe that by ‘taking’ something away, it increases their abundance (it’s actually the opposite: this mindset causes *more* scarcity in the person holding those thoughts/pursuing those behaviors).
We can sense this intention energetically by how we ‘feel’ (restricted/confined/nauseous etc) which goes beyond simply feeling triggered (a trigger feels like a ‘poke from the inside’ whereas a harmful intention feels like a ‘poke from the outside’)
*Boundaries are key for this type of mirror — compassionate distance (so not anger or vengefulness) is best. Confronting or discussing this is of no use as they lack self-awareness; once their core wounds are healing they may make those shifts on their own**
A few things to note: “bad mirrors” tend to have *different* wounds compared to ourselves. For instance, a bad mirror triggered by envy in another is more likely if the ‘subject’ of the envy does not have scarcity as a wound.
Case study on this distinction:
Lena is a [conventionally] beautiful woman who is intelligent and dynamic, passionate and confident. She enjoys a healthy relationship, fulfilling work, and a beautiful home, and generally has an ‘abundant’ mindset. Her own wounding (and opportunity to heal) may be around the value of ‘freedom,’ and feeling triggered by individuals who attempt to control/suppress/confine her. This may manifest in various ways: rebelling against the rules, becoming upset if a friend makes a suggestion to ‘change’ in a way that seems confining, and so forth. Her ‘good mirrors’ are those who intend to help her integrate, even if their suggestions can be triggering (and thus invitations to evolve/heal). For example, if a friend invites her to a journalling workshop — Lena may, if unintegrated, interpret it as a controlling exercise to change an existing routine, even if the friend has only compassionate intentions.
On the other hand ‘bad mirrors’ are those that *may* outwardly express a desire to control (e.g. comments like “you should be more like…[confining/small]”) but more often than not the deeper issue here may be an entirely different wound such as scarcity, which, to use the same example, runs against Lena’s ‘abundant mindset.’ Her ‘bad mirrors’ may be triggered by: Lena’s confidence, beauty, relationship, home, profession, and so forth, which can come through as aggressive attacks (directed to her about her home, by someone who is ashamed of their living situation), passive-aggressive comments (about her appearance, by someone ashamed of their weight/physical appearance) or gossip (directed to others about relationship, by someone ashamed of their own relationship), sabotage (directed about her work performance, by someone threatened by her abilities).
Even if some of these comments come across as ‘controlling’ (e.g. ‘you should [cut your hair, move, do fewer presentations, etc]’ the deeper motivation here is envy(scarcity mindset). As such, even if Lena is aware and able to set boundaries, often the longer-term solution is compassionate distance, which may or may not invite the other into self-reflection and their own healing.
From a rational point of view, Lena may have trouble understanding the scarcity mindset/envy by others simply because it isn’t reflective of her own conditioning (and similarly others may have trouble understanding triggers around freedom/control). So, any attempts to rationalize or “understand” the behavior of ‘bad mirrors’ are rarely effective, and deference to boundary setting and/or distance remains central. This helps explain the common question 'why would they behave this way?' -- it's challenging to understand behavior that is an outgrowth of a wound we have no lived experience with (it appears 'irrational').
2)Teachers
These are individuals who have unique knowledge and/or experience (rational and spiritual) that allows us to expand our own lived experience and understanding of consciousness, our purpose, life, etc. They may have ‘more’ knowledge or experience or ‘deeper’ knowledge or experience (so age/life stage matters but only to a degree — it’s more linked to our ‘soul’s evolutionary stage’ which is different from human age/earth age).
We recognize teachers because we feel energized, peaceful, inspired and more curious about the world. We don’t feel triggered around them either — we simply feel more connected to ourselves and the universe.
3)Expanders
These are individuals who are, intentionally or not, able to amplify our desires and goals in life. This can be rationally (they simply ‘have’ the ‘things we want and need’ and can ‘provide’ them to us), spiritually (they are skilled at bringing forth their own desires/manifestations, and amplify ours in the process), or a mix of both. They help us see and feel what’s possible.
We recognize expanders because we feel inspired and excited but also ‘clear and confident’ about our desires. It’s a sense that ‘they want that thing for me too! they believe it as much as I do.’
One final point:
Good mirrors can also have expansive qualities and teacher qualities (and likely transform onto one or the other over time). While uncommon, it is possible for an expander or teacher to 'regress' into a good mirror (if we begin to feel triggered again/a new wounding experience leads to a new trigger) or a harmful 'bad' mirror. Example of a regression into a bad mirror:
~a formerly 'abundant' person who experiences financial and/or professional hardship, a re-wounding of a scarcity mindset, and envy
~a formerly 'secure' person who experiences relationship struggles (infidelity, a realization of a lack of alignment) and a re-wounding that results in envy/jealousy of another's relationship
~a formerly 'secure' person who experiences a shift in their appearance (e.g. weight loss) that has not resulted in a desired outcome (more confidence) and a re-wounding around learned helplessness (can lead to envy or obsessive/controlling behaviors around this wound)
So when it comes to our energy and boundaries, we must trust ourselves (use rationality but also how we ‘feel’ — and recognize and honor this). Choose wisely.
A physician’s suicide reminds us that the plague of COVID-19 creates deep emotional wounds in health care workers
One of the oldest tales in the history of medicine is the story of the archetypal “wounded healer,” Chiron. As legend goes, Chiron, an immortal centaur, who both taught medicine and served as a physician, attended a gathering hosted by another centaur named Pholus. After a series of events involving other centaurs fighting over wine, Heracles (aka Hercules), in his attempt to intervene, accidentally unleashed a poisoned arrow that hit Chiron’s knee. Chiron, being immortal, was forced to endure unbearable pain.
Despite his ability to heal others, Chiron was unable to heal himself. Filled with shame, he retreated back to his cave, still committed to teaching his disciples. Eventually, after nine days, his pain became unbearable and Chiron requested that Zeus remove his immortality so he could die. Though a myth, it serves as the first documented story of a physician suicide, albeit assisted, and suggests that the challenge of healing our healers stretches back centuries.
The recent suicide of Lorna Breen, an accomplished and compassionate physician, researcher, colleague, friend, sister and daughter, after she served on the front lines of a busy New York City emergency department, reminds us that the plague of COVID-19 also creates deep emotional wounds in health care workers. As her father Philip Breen described her, she“was like the fireman who runs into the burning building to save another life and doesn’t regard anything about herself.” Her death was not due to COVID-19; it was due to a system and culture of hospital medicine that failed to value her as a human beyond her profession.
Right now, COVID-19 is a stress test, exposing the vulnerabilities in our financial, social welfare and health care systems. But it’s also a catalyst, giving rise to novel solutions such as providing a guaranteed basic income, expanding blood donation eligibility, reducing bureaucracy in hospitals and encouraging partnerships between tech companies. As such, it must also be a catalyst for improving medical culture so that one day no physician is forced to choose suicide as a result of an inability to cope or seek healing for themselves.
Awareness of the suicide epidemic plaguing the profession has gained ground over the last five years. Doctors have the highest suicide rate of any profession: about 300 doctors die each year in the United States (the size of a typical medical school student body). Effectively, suicide has now become an occupational hazard of the profession. But it’s also the canary in a coal mine serving as a warning for an overwhelmed and unhealthy system, one that doesn’t care for its doctors.
One thing is painfully clear: physician suicide isn’t about resilience. Doctors by definition are resilient; we must be to jump through many hoops to gain admission, serve on long overnight calls often without food, water or sleep, and work unreasonable work hours, often with an inadequate support system. Sadly the overemphasis on individual resilience at the expense of ensuring the work environment is healthy has placed the onus on doctors themselves—which is nothing more than victim-blaming.
While substance use and mental illness may be factors, many doctors do not have a diagnosed mental health disorder like depression and anxiety. This may, in part, be due to stigma around seeking a formal diagnosis, but we also know that symptoms of depression are wildly dependent on the environment; the influence of our situation on our reactions has been understood by sociologists for decades.
While things like mindfulness help to a degree, it’s a lot like expecting a soldier to meditate while bombs are being dropped all around her. The priority must instead be to get that soldier into a safe space with a battalion she can rely on, with the appropriate protective gear. Putting an otherwise healthy person, someone who is driven, intelligent, empathetic, in an environment that is not conducive to her well-being will place additional pressures on her with little room to thrive, or possibly even survive. The consequences can be disastrous, but are not surprising.
The problem of physician suicide is so deep, and the role of culture so paramount, that pontificating on solutions often feels futile, especially as the issue isn’t so much what the solutions are, but how to actualize them.
Culture must change from the top down, and this takes sound policies and commitment. Policies must include limits on work hours, time for self-care, and zero tolerance for bullying and harassment. We must also increase psychological safety (defined by Harvard scholar Amy Edmondson as “a climate in which people are comfortable expressing and being themselves”), a matter that is a pressing issue during the pandemic, as with the firing of doctors in Mississippi who have voiced concerns.
We should also ensure that all physician health programs are free of conflict of interest, completely divorced from licensing bodies, and accessible both geographically and financially. During a crisis especially, as we know from humanitarian aid workers, reentry trauma is common, and so access to these programs now is paramount in order to offset the risk of suffering alone. Isolation is an unsafe breeding ground for trauma, anxiety, and unprocessed grief.
Beyond telling the story of Chiron’s death, the ancient Greeks came to see suicide as primarily due to malfunctional “humors”—the end result of the build-up of black bile (melancholia) or yellow bile (mania). The beauty of medical knowledge is that it evolves; so too must our understanding. We must take lessons from as far back as Chiron, and as recently as Lorna Breen, to understand that environmental factors matter much more than the individual. Breen’s passing during this pandemic offers us a moment to reflect on how best to use our outrage and mourning, as patients and physicians, to finally move out of the clouds of ignorance, willful blindness and institutional inertia to prevent the same tragedy for repeating itself.
Once Chiron died, he left two legacies. The first was in those he taught: like the father of medicine, Asclepius, who in turn was said to have taught Hippocrates. Thousands of medical students take the Hippocratic oath each year. The second legacy, according to the poet Ovid, was through a gift from Zeus, who wanted to ensure Chiron’s spirit lived on in the night sky, so he created the constellation Centaurus—what may now be viewed a literal interpretation of the saying per aspera ad astra (“through hardship, to the stars”).
It shines brightest during the month of May. This year it might remind us of the thousands of physicians who took their own lives while healing others—some during this pandemic—doctors who might inspire us to finally change direction. And for Breen, as one of those bright stars, may we also vow to honor you as the hero you were, illuminating our path forward.
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources. Here’s what you can do when a loved one is severely depressed. For physicians on the front lines expressing mental distress or suicidal thoughts, or who just wish to talk, call the Physician Support Line 1-888-409-0141, which is open 8am to 3am ET, seven days a week, and provides free and confidential support with a volunteer psychiatrist.
**Originally published in Scientific American**
The coronavirus pandemic will leave lasting emotional scars.
According to my mother, there are two unique forms of grief that everyone touched by war understands. There’s the grief associated with the loss of human life—through bombings and brutal combat, and through the disease that runs rampant when health care and all other social services are halted. Then there’s the grief associated with the loss of a life as we once knew it: loss of country, loss of employment, loss of identity as a “prewar person,” and the subsequent need to start over. The two run along together like two dark snakes intertwined.
When my mother and father moved to the United Kingdom from Sri Lanka, amid a civil war that would drag on for 26 years, they didn’t readily display their grief. My siblings were born into the only reality we would ever know: visiting ducks at the local park, swinging on our neighbors’ swing set, and blowing out candles at birthday parties that were evidence of both assimilation and normalcy. Yet my parents’ grief would peek through at moments. The first time I ever saw my mother sob was the day she received a phone call with news that my uncle back home had lost his foot in a land-mine explosion. Years after we had moved to Canada, she learned that a famous library holding thousands of historical texts in her native Jaffna had been burned to the ground by the army. Her silent tears and the way she stared off into space, I realized then, were two more dialects of grief.
That kind of sorrow is unfamiliar to many people who live in peaceful places. Yet COVID-19 will leave behind a complicated form of grief that will linger—potentially for many years after the immediate crisis has abated. Thousands of bodies have piled up in Italy, during a period when doctors wrestled with horrific ethical quandaries around rationing care. Now, in parts of the United States, refrigerated trucks have been deployed for use as makeshift morgues. In New York, a mass grave is being built, and cremations are happening all day long. Patients are dying alone, and much like during the Ebola crisis in West Africa, fears of contagion have interfered with families’ ability to mourn.
As of yesterday afternoon, more than 20,000 Americans had died of the new coronavirus. The growth in the number of cases, fortunately, appears to be slowing. Still, even relatively optimistic projections indicate that many more people will succumb in coming weeks; even some who recover will still be at risk of long-term health complications.
All of this damage is occurring while people are still dying from other causes, too—and when grieving people are being discouraged from even going outside, much less seeking solace from their loved ones. Making matters worse, the current crisis has put enormous stress on the healing professions that, in normal times, help families deal with loss and bereavement. Our society is ill-prepared for the kind of grief the coronavirus is visiting upon so many people during so short a span.
Research on grief after large-scale casualties is scant, but the literature suggests that suffering personal losses can be particularly harmful when experienced in times of broader social stress. A 2015 study found that children who lost a loved one during a mass-trauma event such as a natural disaster, a terrorist attack, or a war are likely to suffer long-term psychological trouble. Studies of service members and veterans who served during 9/11 found a high prevalence of what is sometimes called complicated grief—a type of bereavement that is unusually severe and long-lasting. These service members and veterans showed worse symptoms of post-traumatic stress disorder and had a higher number of lifetime suicide attempts.
A study of survivors of the Rwandan genocide found that what the researcher called “unprocessed mourning”—in part the result of the halting of traditional mourning rituals during the war—contributed to lingering mental-health woes. Two years after the 2004 Indian Ocean tsunami, chronic grief was found in almost half the survivors, and was strongly associated with losing a spouse or being female. And a systematic review of Ebola survivors found high levels of psychological distress, including prolonged grief, which was compounded by the stigma placed both on survivors and their families as they attempted to return to work.
The coronavirus pandemic differs from those catastrophes in various ways. But it brings stressors of its own. Especially for those worried about vulnerable elders, it brings a level of anticipatory grief, the form that appears when the death of a loved one appears inevitable. It also comes amid a sudden economic crisis and skyrocketing unemployment; the disconnection of people from their families, friends, and their usual routines; and the recognition that some of those routines will be permanently disrupted.
In her 1939 short story Pale Horse, Pale Rider, the writer Katherine Anne Porter describes the protagonist, Miranda, as she falls in love with a soldier named Adam while also falling ill with the 1918 influenza. Amid their fear of the disease, the pair also grieve their old way of life. “All the theatres and nearly all the shops and restaurants are closed,” Adam laments, “and the streets have been full of funerals all day and ambulances all night.” Only when Miranda recovers herself can she fully appreciate the world she and her lover have lost. And when she learns, by letter, that her lover has died from the disease, she descends into the darker depths of prolonged grief.
“At once he was there beside her, invisible but urgently present, a ghost more alive than she was, the last intolerable cheat of her heart; for knowing it was false she still clung to the lie, the unpardonable lie of her bitter desire.”
The Diagnostic and Statistical Manual of Mental Disorders defines prolonged grief disorder as grief symptoms persisting for six months or longer after a loss, along with separation distress, impaired social or occupational functioning, and the presence of symptoms such as confusion, shock, bitterness, and difficulty moving forward with life. As the public sits in anxiety and in isolation, policy makers seeking to cope with the current crisis must also begin to plan for the demands on mental-health services, specifically for grief and bereavement, in the near term and beyond.
As a physician who is also the child of two physicians, I worry in particular about the grief experienced by the health-care providers who are making good on their ethical duty to serve those suffering from the coronavirus. After the 2004 tsunami, prolonged grief disorder was found in one in 10 hospital workers surveyed. In the current crisis, medical providers—including my mother, an anesthesiologist who performs intubations—are at personal risk. Even those who survive COVID-19 or do not contract it in the first place may lose valued friends and colleagues, amid the deaths of other health-care workers who have had to work without adequate protective gear.
In the hospital, doctors and patients alike have reasons to grieve. Doctors grieve the loss of a patient who has died. Patients, once a disease is diagnosed, grieve the loss of their health. Medical trainees grieve their former idealistic self as they become inured to a system that, ironically, often places little value on their own well-being.
Before the coronavirus, the ethos of humanism—of listening closely to patients’ concerns and fears and tending to their needs—had never been stronger in the medical profession. The pandemic returns doctors to a time when compartmentalizing a patient’s suffering—and one’s own—is an emotional survival tool. “We’re asked to be as dispassionate as the disease itself,” Daniel Lakoff, an emergency-room doctor in New York City, recently told me. “We don’t touch the patient in many cases, we use telemedicine, we give oxygen, and we watch and wait. And we often feel powerless.”
Claire Bidwell Smith, a counselor in Charleston, South Carolina, who has written three books on grief, told me that these recent weeks have been the busiest of her decade-long career. (She offers her services online.) She raises the possibility that grief may play out differently during this pandemic from how most people typically experience it. Usually grief feels very personal, Smith says, because the rest of the world proceeds normally while the bereaved feels numb and alone. That dynamic may change because much of the world has now ground to a halt. Grief may be delayed, she said, but a shared catharsis may lie ahead. “I think there will be a massive collective mourning when we’ve emerged from this, for us as a culture,” Smith said. “While what’s happening is heartbreaking, and we haven’t been able to ritualize or memorialize. We will come back to this.”
When I was growing up, another way in which grief visited our home was when my parents’ friends and extended family from Sri Lanka would stop by and reminisce. They would briefly recall the war but also use it as a frame in which to tell more uplifting stories of laughter and overcoming. Grief, when these adults experienced it together, became a connecting agent, joining the broken pieces into a more harmonious common mosaic.
The scars always remain. At the end of Pale Horse, Pale Rider, months of hardship give way to a future that is both brighter and tinged with melancholy. “No more war, no more plague,” she writes, “only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold light of tomorrow. Now there would be time for everything.”
**Originally published in The Atlantic**
The secret to sticking with your resolutions may be having a coach to help strategize and cheer you on.
My teenage patient looked nervous as I reviewed her glucose readings from her glucometer and her glucose logbook, which people with diabetes use to track their blood-sugar test results. There were a lot of high levels — ranges in the 12’s and 14’s, when the goal was around 7 or 8. The peaks were mostly in the middle of the day and on weekends. (This was in Canada; blood glucose readings of 12 to 14 are equivalent to 216 to 250 mg/dL in the United States.)
“What do you usually eat at home?” I asked. She said that her mother was careful to make her a breakfast that balanced carbohydrates with protein. Her dinners were similar.
“What do you usually eat at lunch?” I asked. My patient started tearing up. She ate whatever her friends were eating in her high school’s cafeteria that day — like spaghetti, hamburgers or pizza, and something like a cupcake for dessert. This was probably what led to her readings being so high.
She had met with diabetes educators before, and she knew what uncontrolled glucose does to a person with diabetes, from speeding up nerve damage in the feet to hastening blood vessel damage in the back of the eyes and the kidneys, to increasing her risk of heart disease.
I knew she could have told me all of that, so lecturing her wasn’t going to help.
Instead my patient needed empathy and the tools to help her make healthier decisions, and part of that required understanding what was important to her, specifically “fitting in” with her friends in high school, the ones who didn’t have a chronic disease. It also would have involved helping her find the motivation within herself to make the change.
But my skill set for helping her was limited, especially on top of everything else I had to cover within our allotted time of 45 minutes.
Research suggests that behavioral and lifestyle factors are a big part of what contributes to chronic disease. In medical training, we learn a lot about the body and how to prevent and treat disease, but little about how we can motivate a patient to change old habits or even stick with a current management plan.
It struck me that what my patient really needed was a coach. At this time of year when many of us have made resolutions to get healthier, working with a health coach might be one way to reach those goals.
A health coach is someone trained in behavior change, who primarily uses an interview style called “motivational interviewing” to help patients see their ability to make change. While some may have clinical training in fields like nursing or medicine, they hail from a wide variety of disciplines or train in health coaching as a secondary career.
As a relatively young field, it’s still finding its footing — for instance, a systematic review found that the definitions of “health coaching” varied widely, though the authors recommended that health coaches take a patient-centered approach to help with goal setting while encouraging self-discovery and accountability.
The evidence that health coaching may spur general lifestyle changes is mounting. A 2018 study looked at clinical trials for coaching for nutrition and weight management and found that over 80 percent of these studies found improvement. And a 2017 study found that coaching can lead to increased physical activity in older adults. Studies suggest that health coaching may also provide benefits for conditions such as obesity and diabetes as well as attention deficit hyperactivity disorder, chronic pain, hypertension and high cholesterol. A recent review found that health coaching can improve quality of life and reduce hospital admissions among patients with chronic obstructive pulmonary disease, and it may help patients to become more engaged in the health care system.
It may even improve health outcomes through encouraging patient adherence to medication.
“Health coaching recognizes that we cannot help people by expecting them to act if that person is not ready to act,” said Leila Finn, a health coach based in Atlanta. “We help people take big goals and break them down into accessible, bite-size pieces — not by telling clients what to do but by helping clients figure out what will work for them.”
Health coaching gets to the heart of what providing good health care is about: acceptance, partnership, compassion, and helping patients feel respected and understood.
Though my clinical training is in pediatric medicine, inspired by what I had read, I recently completed a certificate in health coaching myself. The experience was eye-opening and humbling. I learned new ways of communicating with my patients, specifically ways to encourage them to see their own ability to make lifestyle changes while setting manageable goals. I also learned ways to cheer them on when they reach their goals, without shaming them if they relapse: Both pieces are critical to the process of making sustainable change.
While research is beginning to show the value of health coaching, the principles of communicating with the intent to inspire and motivate are transferable to all health professions — and could reap dividends if taught early on in the training of nursing students, medical students, pharmacy students, and other allied health professionals.
And when I think back to my teenage patient with diabetes, while I was empathetic, that was only half of the solution. The second half could have involved coaching her to see which small changes she could begin to make moving forward. I’m hoping that choosing my words more effectively, even within the pressures of time, may make all the difference for my other patients.
**Originally published in the New York Times**
When pain researcher Diane Gromala recounts how she started in the field of virtual reality, she seems reflective.
She had been researching virtual reality for pain since the early 1990s, but her shift to focusing on how virtual reality could be used for chronic pain management began in 1999, when her own chronic pain became worse. Prior to that, her focus was on VR as entertainment.
Gromala, 56, was diagnosed with chronic pain in 1984, but the left-sided pain that extended from her lower stomach to her left leg worsened over the next 15 years.
“Taking care of my chronic pain became a full-time job. So at some point I had to make a choice — either stop working or charge full force ahead by making it a motivation for my research. You can guess what I chose,” she said.
Now she’s finding that immersive VR technology may offer another option for chronic pain, which affects at least one in five Canadians, according to a 2011 University of Alberta study.
“We know that there is some evidence supporting immersive VR for acute pain, so it’s reasonable to look into how it could help patients that suffer from chronic pain.”
Gromala has a PhD in human computer interaction and holds the Canada Research Chair in Computational Technologies for Transforming Pain. She also directs the pain studies lab and the Chronic Pain Research Institute at Simon Fraser University in Burnaby, B.C.
Using VR to relieve or treat acute pain has been done for a while.
In the 1990s, researcher Hunter Hoffman conducted one of the earliest studies looking at VR for pain relief in the University of Wisconsin human interface technology lab. His initial focus was burn victims.
Movement and exercise
Since then, the field has expanded. Gromala’s lab focuses on bringing evidence-based therapies that work specifically for chronic pain, such as mindfulness-based stress reduction. They have published studies on their virtual meditative walk to guide and relax patients.
Movement and exercise are a key part of chronic pain management in general. But for many patients, it can be too difficult.
“Through VR we can help create an environment where, with a VR headset, they can feel like they are walking through a forest, all while hearing a guided walking meditation,” Gromala said.
The team also designed a meditation chamber — where a person lies in the enclosed space, breathing becomes more relaxed and a jellyfish viewed through VR dissolves.
Each experiment gives real-time feedback to the patient through objective measures of pain such as skin temperature and heart rate. For instance, while feeling pain, skin surface temperature and heart rate can increase.
While pain medications can be important, chronic pain treatment should also address lifestyle aspects, says Neil Jamensky, a Toronto anesthesiologist and chronic pain specialist.
“Physical rehabilitation therapy, psychological support and optimizing things like nutrition, exercise, sleep and relaxation practices all play key roles in chronic pain management,” he said.
Going global
Other researchers like Sweden’s Dr. Max Ortiz-Catalan from Chalmers University of Technology have looked at virtual and augmented reality for phantom limb pain — the particularly challenging syndrome among amputees who experience pain in a limb that is not physically there.
In his study, published in The Lancet in December 2016, Ortiz-Catalan demonstrated a 47 per cent reduction in symptoms among VR participants.
He believes the reason behind it is a “retraining” of the brain, where pathways in the brain effectively re-route themselves to focus more on movement, for instance.
“We demonstrated that if an amputee can see and manipulate a ‘virtual’ limb — which is projected over their limb stump — in space, over time, the brain retrains these areas.
“Through this retraining, the brain reorganizes itself to focus on motor control and less on pain firing,” said Ortiz-Catalan.
With only 14 patients, this was a pilot study, but he plans to expand the work into a multi-centre, multi-country study later this year. The University of New Brunswick is one of the planned study sites.
There’s an app for this
Others in the United States have published their own findings of VR for chronic pain.
Last month, Ted Jones and colleagues from Knoxville released results of their pilot study of 30 chronic pain patients who were offered five-minute sessions using a VR application called “Cool!” — an immersive VR program administered through a computer and viewed through a head-mounted device.
All reported a decrease in pain while using the app — some decreased by 60 per cent — and post-session pain decreased by 33 per cent. The findings were presented in the journal PLoS.
“What was interesting to observe was that the pain decreased for six to 48 hours post-VR experience. It’s not as long as we would like, but does illustrate that relief can be sustained over some period of time,” Jones said.
His team will be expanding the research this year and will also look at how VR can help with the challenging mental health side-effects of chronic pain.
Next steps
Jamensky points out while VR could be a promising treatment one day, one challenge with clinical trials is the dependence on looking at pain scores when assessing the effectiveness of VR. This may overshadow individual patient goals.
For instance, while the ability to decrease any individual’s pain score from a “seven out of 10” to a “three out of 10” can be challenging, improving functionality and quality of life can often be more valuable to the patient.
“A pain score may not always be the best way to assess treatment success, since the therapeutic goal may not be to eliminate pain or improve this score, but to ensure better sleep, better mobility, improved mood or even an ability to return to work,” he said.
VR as a technology for chronic pain management is in its infancy. Gromala notes that further research, in addition to standardizing the VR delivery devices, is needed before it becomes a standard of care. And future studies must include practical outcomes.
“It is important to realize that the ‘pain’ of chronic pain may never go away, and that ultimately the individual must learn to deal with the pain so that they can function better,” Jamensky said.
Gromala agrees.
For her, developing an awareness for how sleep, mood and exercise affect her own pain experience has made a huge difference.
In fact, it has motivated her to continue both advocating for chronic pain patients and to partner with clinical pain specialists on research.
” ‘Taking care of yourself’ means a different thing for chronic pain sufferers. It’s much tougher,” Gromala said.
“So as researchers we have a big task ahead of us, and sometimes it means exploring whether out-of-the-box methods like VR can help.”
**Originally published on CBC.ca**
“Bring yourself back to your awareness,” said Sara Auster, a self-proclaimed sound healer, after 45 minutes in a ballroom at a hotel in Chicago where she created vibrations using crystal bowls and tuning forks as well as a traditional Indian accordion, known as a shruti box. Seventy-five people got up like a gaggle of toddlers being shaken from a nap.
The session, which cost $30, and was like many popping up in churches, community centers and even some prisons and hospitals. The goal, practitioners say, is to use sound to tackle individual and collective anxiety, depression, insomnia and more.
Recently, musicians like Erykah Badu and the Icelandic band Sigur Ros have also dipped into sound healing.
Over in the tech world, mindfulness is deeply in vogue. Jack Dorsey, the chief executive of Twitter, swears by meditation. Since 2016, Ms. Auster, 40, has been invited as well to perform for various Google company initiatives. This past April, Adrian DiMatteo, a musician in Brooklyn who has a degree in jazz performance, led a sound bath in the neighborhood of Greenpoint for leaders at Instagram. (“They approached us to do a corporate bonding event, as they’re moving towards doing more events without alcohol,” Mr. DiMatteo said. “They had lots of questions about the instruments and the bowls.”)
Some health facilities have taken note as well. Ms. Auster has performed for Harlem House Clubhouse, an outpatient psychiatric rehabilitation program at Harlem Hospital in New York. Darren Austin Hall, a ceremonial musician and sound healer in Toronto, has performed in the atrium of Toronto General Hospital with a Canadian organization called Music Can Heal.
The Children’s Hospital of Philadelphia has also discussed incorporating sound baths. Mr. DiMatteo has offered them in the waiting area at NYU Langone through a program called Music That Heals, as well as at Coney Island Hospital and “about a dozen others,” he said.
Diane Mandle, who has offered sound healing in Encinitas, Calif., for 19 years, said: “It’s not curing, it’s healing.” She has also provided sound sessions in an oncology unit at Sharp Memorial Hospital in San Diego, as well as at a workshop for inmates at the Vista Detention Center.
“Healing is an ongoing process that contributes to a better sense of well-being,” Ms. Mandle said.
What are sound baths?
Sound baths are an experience in which a group of people gather, often while lying on a mat, to listen to sounds produced through various instruments. There is no licensing procedure for leading sound baths, and though Ms. Auster wouldn’t say where she received her training, her music background and meditation training are strong influences.
For centuries, various cultures, including my own, South Asian, have used sound as a part of religious ceremonies and prayer, with one goal being to promote and facilitate meditation. In that sense, it’s not terribly different from singing hymns in a church. Most religions and cultures use music and sound for spiritual reasons.
But what about the promise of healing? After all, the use of sound is advertised as an activity that can do many things, including “realigning your chakras” and “mind expansion.”
“Personally I have an issue with the word ‘healer,’ which is why I turn down a lot of wellness events,” Ms. Auster said. “There are all sorts of expectations with that label, and I don’t want to be seen as some magical guru person or for people to assume they could not possibly have an understanding of the experience.”
Like other forms of music, sound baths bring people together, but with an added meditative element. Anaïs Maviel, a musician in New York, said that she is often asked to perform for grass-roots organizations as part of “community-building” efforts.
Does sound have an effect on our health?
One way sound is related to health is through noise pollution: traffic noise, planes flying overhead, loud concerts. The World Health Organization lists noise pollution as an increasing threat to human health, and recently set limits on environmental noise.
This may also explain the boom in A.S.M.R. — soothing sounds that, like sound baths, aim to address stress and anxiety. A.S.M.R. has become an internet phenomenon, particularly on platforms like YouTube.
Sound, in the form of music, has been used for various conditions, including dementia. As Oliver Sacks wrote in his book “Musicophilia,” a variety of neurological conditions including symptoms of dementia and psychiatric conditions like depression and schizophrenia may also benefit from music.
But where is the evidence for sound baths? It’s unclear when “sound healing” was first used. However, medicine has used the concept for years specifically for acoustic therapy for tinnitus, a condition that involves hearing unwanted noise without a clear stimulus.
With tinnitus, essentially, the brain perceives sound as entering the ear, even though there is no sound. It is similar to phantom pain in that regard: a situation in which there is a misperception that can cause immense grief.
Often described as “acoustic therapy,” sound healing was listed as an appropriate treatment in clinical practice guidelines. But this therapy involves neither bowls nor chimes. It is typically a form of low-frequency white noise played through a hearing aid or through an app.
A 2013 study of tinnitus, led by David Baguley, a professor of hearing sciences at the University of Nottingham, listed acoustic therapy as one of several interventions. However, in December 2018 a review of existing studies found no evidence of using sound versus placebo for tinnitus.
“Well, the absence of evidence doesn’t mean absence of benefit,” Dr. Baguley said. He also noted that some patients choose calming nature or ocean sounds as opposed to white noise, which could overlap with the suggested benefits of sound baths.
“It’s more than just a distracting noise,” Dr. Baguley said. “We know that sound has a massive influence on how the brain is organized.”
So, do sound baths actually heal?
A 2014 study found that for patients being weaned off mechanical ventilation, providing them with sounds of nature significantly reduced agitation and anxiety, as measured through heart rate, expressions of pain and blood pressure, when compared with patients who did not listen to these sounds.
More recently, a research psychologist reported that singing bowl sound meditation was helpful in reducing tension, depression symptoms, fatigue and anger in a group of 62 adults.
So far, the evidence for sound healing is limited, and is aligned with what we know about the effects of calming music and the benefits of meditation.
Ms. Auster also believes that one of the biggest benefits of sound baths is that they facilitate community.
“It’s people coming together to release and let go, but in the company of others around them,” she said. “If meditation is taking the stairs, a sound bath is taking the elevator.”
**Originally published in the New York Times**
For youth and children, there is a plethora of scientific evidence for mindfulness practices in this group, allowing programs to develop evidence-based initiatives for schools, while also incorporating evaluation of their programs.
Mindfulness has been defined by Susan Kaiser Greenland as “the capacity to be alert and open to life experience as it occurs in a non-reactive, resilient, and compassionate way.” Popularized in the west by Dr. Jon Kabat-Zinn, mindfulness may also be described as “paying attention on purpose, in the present moment, nonjudgmentally.” While secular, it derives its origins from Hinduism and Buddhism and has gained popularity in recent years, both as a tool for self-care but also within structured initiatives to manage stress, anxiety, and depression.
There have been a number of studies looking at the effects of mindfulness for a variety of things — anything from stress, overeating (and eating disorders involving food restriction), memory, and self-esteem. In particular, for youth and children, there is a plethora of scientific evidence for mindfulness practices in this group, allowing programs to develop evidence-based initiatives for schools, while also incorporating evaluation of their programs.
New initiatives such as Mindup, Mindfulness in Schools, and Mindfulness Without Borders have flourished, as they offer unique curricula that can be used in the classroom to improve mental health and coping strategies among students.
Over the last two years, books such as A Still and Quiet Place by Dr.Amy Saltzman and The Mindful Teen by Dr. Dzung Vo have provided teachers, parents, and healthcare providers with techniques to incorporate mindfulness practices with children and youth.
This past summer I had an opportunity to complete a facilitator workshop with Mindfulness Without Borders (MWB), a Canadian charity, that teaches youth, educators, professionals and parents essential skills and strategies to increase attention, regulate emotions, build resilience, and be more compassionate towards others in a high stress world. The workshop focused on their robust evidence-based curriculum on mindfulness techniques for youth, and prepares facilitators to lead what is traditionally a 12-session workshop in classrooms and other youth settings. MWB’s programs are active within the Toronto Catholic District School Board, YMCA Academy, select Toronto District School Board High Schools and the York Regional Police. There is an upcoming training in Toronto through the Applied Mindfulness and Meditation Program at the University of Toronto, and a number of online opportunities to learn more about mindfulness techniques for youth on the website.
Here are just four of the techniques we covered, that are described in more detail on the MWB website. They can be tools to use on yourself, or with a child or youth in your life who expresses interest. I have linked to an audio example of each practice below.
1.Mindful Listening: This technique brings awareness into the way we typically listen (usually with a purpose and agenda to formulate our own responses), and encourages us to stay open to the speakers perspective while releasing our own personal agendas.
2.Tuza: Tuza means “slow down and relax,” in a Rwandan dialect, and is a breathing technique used to restore a sense of calm and balance in challenging situations.
3.Take Five: This is a breathing technique intended to center our mind and our breath (both which tend to become frantic during stressful situations), bringing regularity to our breathing. It begins with a deep inhale, a pause, and a slow exhale, followed by another pause. This can be repeated at least four other times (hence “take five”) in overwhelming situations.
4.Body Scan: The body scan is a popular mindfulness technique used anytime during the day, and can be particularly helpful before sleep, in an effort to relax the mind and body. This tool involves “intentional attention” placed on one part of the body at a time, encouraging openness and curiosity.
**This blog was originally published on Huffingtonpost.ca**
