Happy (almost) Pride Month to all of our LGBTQIA+ brothers, sisters, and siblings! True to form, I will start this next section with a bit of history:
June was established as Pride Month after the Stonewall riots in June of 1968. Stonewall Inn was the name of a gay bar in New York City where police officers forcibly dragged patrons and employees because gay behavior in public was still ILLEGAL at this time. This event sparked 6 days of riots in Greenwich Village and ignited the gay rights movement in the United States. This month, I am celebrating by reflecting on my relative privilege as a straight person and my privilege in general. I know a lot more about being privileged than I do about being marginalized and, as with all of my writing and creative pursuits, I wish to stay in my lane. The following is a reflection on my experience of privilege: Somatically, my experience of privilege is often an experience of the absence of pervasive anxiety, rage, shame, and dread relative to my experience of oppression. I remember the surprise I felt when one of my mentors mentioned that he came out before “homosexuality” was removed from the list of psychological pathologies and paraphilias. He discussed needing to hide his true self back then and still at times to this day. I realized at that moment that, even though I have a lot of LGBTQ+ individuals in my personal and professional life, I can easily forget all of the overt and subtle ways that queer identified folks are historically and currently marginalized by means of the basic structures of society. I still frequently have conversations with queer folks that remind me of how much my straightness lacks the relative friction that a queer identity has in our current culture. As someone who has always been “progressive” when it comes to social issues, it's easy to see privilege in people who are overtly racist, queer-phobic, et cetera and harder to see it in myself and others who identify as allies. I do reflect periodically on the marginalization I experience being a woman, especially having lived in Texas the majority of my life. I do not reflect as often or automatically about the experience of skin color privilege, straight privilege, being born in a middle class zip code, et cetera because my privilege in these areas means that I don’t have to think about these aspects of myself and adjust my natural behavior to survive and succeed in life. To me this is what privilege means: fewer obstacles to functioning in my community/country/world, from basic survival all the way to achieving my hopes and dreams. Privilege means I don’t have to think about oppression and marginalization if I don’t want to. I do not spend a lot of time consciously thinking about my marginalized identities (woman/neurodiverse/chronic pain) but when I do reflect, I can see that it is something that I automatically factor in when making life decisions. For example, when Texas appeared to be heading in an anti-woman direction, I decided to leave permanently and reestablish my life in a place that tries to protect women and other marginalized groups. I was aware that I would be moving to a whiter area but I did not have to think about where I would be safe racially in Colorado because I am privileged. I did not have to think about accessibility because I am not disabled. In my career, I have had to think about how I need to dress and present myself because I can be a bit eccentric but not because I was at risk of looking “too queer” which would inspire rejection and opportunity loss due to unconscious or conscious homophobia. I wish I did not have to think about "being a woman" from an oppression standpoint when making life decisions and I wish the same freedom for all other marginalized identities. In fact, I have noticed an historical aversion to reflecting on my marginalized identities because I feel powerless when I do. I have made it more of a point to think about my own marginalization periodically because it brings me into my own reality and fosters compassion in me for other marginalized experiences. I yearn for the day where we live in a world where people are “judged for the content of their character (MLK, Jr)” rather than their social identities. And, even then, when people are unable to show up in a constructive way, I yearn for a world that is trauma informed and treats people with respect for their temperaments and life contexts/histories. I yearn for the day where we live in a world that is inclusive of people of varying abilities, sexual and gender expressions, neurotypes, and wealth statuses. I am calling in a world that is open minded and accessible and eschews dominance and extraction. I believe the best way I can act on that now is by understanding privilege dynamics by seeing them within myself along with giving money, creating opportunity, and doing work in my community that supports marginalized groups.
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I had the great pleasure of seeing the presentation Interstitial Medicine - The Role of Psychiatry in the complex interactions between mental disorders and medical conditions presented by John Hopkins Professor Glenn J. Treisman, MD at the May 2024 Gold Lab Symposium last week. You can watch Dr. Treisman’s talk on YouTube at GoldLab Symposium 2024 DAY 1 - Live Stream starting at minute 17:20. This topic has been a main focus of my practice since beginning in 2011. I’m not as interested in psychiatry perse but I am interested in the “functional neurological” component of mind-body illness. The following is a sort of “book report” on Dr.Treisman’s talk introjecting with some of my own thoughts. People who have chronic pain often have what are called comorbidities. Comorbidity refers to the presence of one or more additional medical conditions co-occurring with a primary condition in a patient. These coexisting conditions can either be related to or independent of the primary condition. Comorbidity is common in both physical and mental health disorders and can complicate the diagnosis, treatment, and management of the primary condition. The siloed non-interdisciplinary nature of the mainstream health care system compounds this difficulty. Dr Treisman in his presentation says, “Everything in the human body affects everything else. We have this weird idea that you can get sick in some way, let's say diabetes, and it's just diabetes. It affects everything. It affects the nerves to your gut, it affects your microbiome, it affects the way in which you think. And we tend not to think about that in medicine, we tend to think about what is right in front of us. The division between mental illness and physical illness is an illusion. It's not true. Your brain is connected to every part of your body. If your foot is sick it affects your brain, if your brain is sick it affects your foot.” Chronic pain used to be thought of as “psychosomatic” meaning the person was simply focusing so much on “pain” that they were causing their nociceptors to fire. Nociceptors are nerves that detect when tissue is undergoing damage. The idea was the nociceptors were being caused to fire by the patient's neurotic obsession with pain and damage while no damage was in fact occurring. We now know this is false. Your pain system is constantly changing and resetting itself. Are you aware of the feeling of your shoes on your feet? Were you aware of this before you read the last sentence? Your brain subtracts the sensation of unimportant information so that you don’t get distracted from sensations and tasks that are a higher priority. When we are more fatigued, depressed, or depleted in some way, it is harder to subtract out unimportant sensations. There are many confirmed chronic pain mechanisms like central sensitization, or sensory amplification caused by nerve damage, but there is a category of pain patients who present with comorbidities of the following:
These disorders, along with chronic pain, are an indicator of the dysregulation of the autonomic nervous system. That means that the nerves, both going to (afferent) and from (efferent) the brain, are damaged in some way. Dysautonomia is often triggered by an infection like Mono or COVID-19. These patients are often told they are “functional” which in mainstream medicine often means “it's all in your head.” We have historically and continue to tell people with real illnesses that they are all made up because the medical field does not know how to treat them medically. We tell them it is something they are doing rather than something they have. More savvy practitioners know that functional means a problem with function rather than structure, i.e. a problem with the software, not the hardware. These patients, therefore, often end up in psychiatry and therapy. Psychiatry and therapy may help with some components of these illnesses, but in my experience, and according to Dr. Treisman, interdisciplinary support is needed for these patients to be successful. The following image represents the interconnectedness of the brain, immune system, gut microbiome, circulatory system, and gut-brain or enteric nervous system. This is a simplified model of how interconnected the brain and body really are. I love the quote from John Barnes: "Is the brain the innermost surface of the skin or the skin the outermost surface of the brain?” If something happens to any component in the system, all other components are affected on a spectrum. That means that someone’s gut microbiome disruption could cause significant migraines in some and minor migraines in others. This system is complex and still being studied with increasing interest. It’s easy to see how the siloed nature of the medical field can miss dysautonomia and other similar conditions since these conditions affect so many different systems at once. Here is another image provided by Dr.Treisman that describes the connection between systems and symptoms. He referred to this as his synthesis of the problem:
Dr. Treisman ends his talk by describing essential information to impart to dysautonomia clients:
Why did I bother writing this up? It is my belief that even as psychotherapists we need to consider differential diagnoses and advocate for our clients with other practitioners until the client sees an improvement in symptoms. Just because clients have been evaluated by medical professionals who have declared their issues to be “psychosomatic,” “functional,” or “all in their head” does not mean that this evaluation is correct. The way I handle this issue in my practice is I provide nervous systems regulation therapies, grief work, and parts work regardless of the medical situation. Nervous system regulation psychotherapy is never medically contraindicated and only helps clients become more resilient regardless of external factors. (*Nervous system regulation psychotherapies can be contraindicated due to certain psychodynamic factors like subpersonalities that do not want the patient to feel better, but that is not a topic that will be treated here.) However, nervous system regulation practices are not enough for many clients and they need medical support if they are to have substantial quality of life improvements. I have long believed that many clients need an interdisciplinary approach when it comes to complex psyche-soma presentations and I feel validated in my perspective by Dr Treisman. A final note: I disagree with Dr Treisman that someone is “well” if they are taking 6 - 12 medications to manage their condition. However, I do view taking medication to be superior to suffering unaided. If taking medication is a strategy that patients need to improve their quality of life, I’m all for it. I am still interested in the medical field at large working to discover ways to address these syndromes with increasingly less damaging interventions that have fewer side effects. I feel hopeful that people like Dr Treisman who promote interdisciplinary approaches are starting the process of uniting the medical field so that we can come up with more sophisticated less damaging treatment approaches. How you feel comes before your thoughts and behavior. This is a surprising notion for people who have a hard time feeling within. Even if you do not have a lot of sensation tied to your emotions or nervous system, you are still being affected by the activity of those systems. It behooves you to gain more access to sensations because, without them, it's like you're driving a car without a dashboard. You are making it down the road to your destination, but you do not know how fast the car is going or if it needs gas and maintenance. People who have more ease feeling within more readily understand this. However, if someone feels a lot of sensation but has a trauma history, they may have an overactive dashboard. The dashboard may tell you what the temperature and weather is like but it is reporting weather conditions from 10 years ago when there was a catastrophic blizzard rather than the current conditions through which you are driving. The body has certain irreducible and non-substitutable needs just like a car. If I put the wrong kind of oil in the car it will either damage it immediately or slowly over time, depending on how wrong the oil is. If I do not give it an oil change, I damage the car. If I drive it too little, damage can happen. If I drive it on the wrong terrain, damage will happen. If I keep it in a corrosive environment, it will wear out sooner. A car that is kept well runs well and can last a long time barring freak accidents. A dashboard that is well synched to the car will reflect how well the car is doing. Nervous system processes occur before you think or feel something. These nervous system processes determine the nature of the thoughts and feelings. The nervous system processes are a combination of the type and state of the car (basic nature of the person combined with a lifetime of experiences aka nurture) in response to the external event. If you wake up on the wrong side of the bed, you are having a certain nervous system response. Let's say you were awakened in the middle of a dream where you were angry at someone and, therefore, you wake up angry. You feel tension in your forehead, a general sense of irritability, your movements are clumsy, and you easily come to frustration that has a kind of friction-in-your-chest feeling. These are the signal of your dashboard. Simple tasks like making coffee and doing the dishes from the night before feel like unfair burdens when normally they are grounding and centering parts of your routine. You may have a sense of feeling wronged and have thoughts about how this-or-that is unfair in your life. You may feel short with your family and you may dread going to work. If someone in this situation is knowledgeable and savvy they would recognize that they are in a sympathetic activation state in their nervous system, which means that their fight or flight system is activated. In this instance this person is in a state of a fight. They would know that in order to come back into balance, they would need to activate their parasympathetic nervous system which is another way of saying they need to calm down. There are many options someone has to choose from when it comes to creating calm. This person chooses to go on a walk and follow that with a cold shower. After their walk and cold shower, their heart feels warm and their body feels refreshed. The feeling of irritability falls away and they have a more resilient attitude towards the day ahead. Notice how this person did not do any talking nor did they do anything complex or special to come back into a balanced mood. The fastest way to come back into balance is to address the nervous system directly which means doing things that change the state of the body. In this example, the person uses exercise and cold exposure. Addressing the body to change nervous system states is as old as civilization. Cold exposure has been prescribed for psychiatric conditions potentially as far back as 3,500 BC (Edwin Smith Papyrus). Socrates points out the importance of physical exercise in Plato’s Theaetetus saying, “Is not the bodily habit spoiled by rest and idleness, but preserved for a long time by motion and exercise?” Cold exposure and exercise are only two items on a long list of proven options of nervous system regulation activities. Other activities include singing, humming, dancing, meditation, stretching, getting outside, receiving massage, drinking water, getting into connection with others, and so on. When we dance fast or slow, making big or small movements, regular or irregular, each quality we apply to the body affects how we feel. When we eat foods that work specifically well for our individual body, and when we eat those foods with other people, it has an effect. Going back to the example of the person who got up grumpy, if they had walked and showered before they did the dishes, the dishes would not have been irritating. Therefore, the dishes are not irritating, the person doing the dishes is irritable. This is a really simple example for something that can become complex when we start thinking about interpersonal interactions. Why is it that one person can demonstrate a lot of patience with “difficult” people and others have none? It's not that the dishes and dealing with difficult people aren't work but individuals have different experiences doing the work depending on the state of their nervous systems. In the image above an agitated and calm nervous system experiences the same event. The agitated person becomes rageful and the next 48 hours are ruined with anger. The calm person is disturbed but comes back to a baseline of calm within 20 minutes after dealing with the difficult experience. Therefore, having chronic nervous system activation puts individuals at a disadvantage because it sets them up for more pain and suffering that a situation warrants.
Basic nature needs to be accounted for as well. If you were born driving a sports car rather than an SUV, you need to stick to the race track rather than trying to go off-roading. If you know about and accept your car, you will make good choices about where to take the car and how to maintain it. If your car finds itself in unfavorable conditions and you have a reliable synched up dashboard, you can make good decisions about how to get your car back to safety and repair any damage that has occurred. The dictum “know thyself” was emblazoned on the Temple of Apollo at Delphi. Lao Tsu said “He who knows others is wise; he who knows himself is enlightened.” When we stop imagining the self and instead relate to it as it is in the here and now, we access choice. No other relationship will ever give us as much choice as the relationship to the self. You have the power to shape your nervous system but first you must learn what the signals mean.
You can consult with experts to help you with your ignorance, confusion, and blind spots but you must take the ultimate responsibility for implementing the actions that make these changes. Do you ever get the feeling of overwhelm or like you're being swept away by an emotional reaction to an event or by life itself? Like a tidal wave, big sensations in the body and wild thoughts in the mind can feel like they are swallowing us whole; like our whole existence is this feeling; that it always has been and always will be. People tend to fear pain. Emotional pain can be just as bad as or worse than physical pain. Emotional pain is physical pain. When we have emotional distress bodies tighten, contorting the tissues into painful knots. A sense of darkness can befall the eyes and a hot metallic fear sears the lungs and face. You can “just get over” emotional pain to the same degree as you can physical pain. It really depends on the severity of the pain. Small pain you can “walk it off.” Big pain takes over your entire existence. Big pain was a common feeling for me throughout my young years. I desperately wanted to get past it but I just couldn't find the way. Life felt like a prison to endure. One day, I had a profound turning point in my experience of the world. At 17 years old, after a significant crisis, I remember standing in the office of a personal growth mentor suddenly feeling like I was looking down on myself and the scene. I felt giddy joy as I began to realize the context in which my pain occurs. I now understand that I gained access to Dual Awareness that day. I was still consumed by pain for long periods of time, but slowly I incorporated more and more of the ability to feel my feelings while simultaneously staying in touch with the context. Dual awareness typically refers to the ability to be aware of both internal experiences (such as thoughts, emotions, bodily sensations) and external stimuli (such as events happening around you) simultaneously. This term is often used in the context of therapy, particularly in approaches like dialectical behavior therapy (DBT) or mindfulness-based therapies like Sensorimotor Psychotherapy. Part of me is directly experiencing what is going on inside my body including sensations, movement impulses, and thoughts while another part of me acts as a Mindful Witnessing Observer (MWO). The MWO observes the inner sensations and external context with curiosity and openness. In therapy, dual awareness involves being able to observe and acknowledge your internal experiences without becoming overwhelmed by them, while also remaining attuned to the external environment. It's a skill that can be particularly helpful for those who struggle with being overtaken by emotions, as it allows them to maintain a balanced perspective and make more intentional choices in response to their experiences. In trauma therapy, we know that we cannot fully process trauma without the presence of dual awareness because, without it, we strengthen the traumatized neural pathway rather than creating a new metabolized experience.
Dual awareness can be cultivated through techniques like mindfulness meditation, where you practice observing your thoughts and feelings without getting caught up in them, while also remaining aware of their surroundings and the present moment. This can lead to increased emotional resilience and a greater sense of overall well-being. Whatever the reason you have for cultivating dual awareness, whether that is to deal with longstanding big pain or simply to increase your sense of wellbeing, you will most likely benefit from the practice. When I first began to have access to dual awareness I felt a major shift in my conscious awareness. While this shift ultimately proved to be beneficial, it was also somewhat confusing and disorienting being so new to me. I also had a tendency to forget to shift into dual awareness for years after. Eventually, I stopped forgetting so much and dual awareness became more of my default rather than something I had to remember. Practices like yoga and meditation helped me intentionally create a relationship with deal awareness but, ultimately, the most important thing was to learn to be in dual awareness throughout the ordinary moments of my days. The result for me has been a huge increase in a sense of trust, appreciation for life, more deliberate responding with less reactivity, and a more compassionate attitude towards myself and others. |
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July 2024
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