On courageous conversations

Last week I attended an education session on Aboriginal and Torres Strait Islander cultural awareness. The intent was to help health professionals engage better with this subset of the Australian population, and as such “close the gap” between the health of non-indigenous and indigenous peoples (who fair terribly worse in morbidity and mortality). The session was run by a man who identified himself as an aboriginal man and he explained various aspects of what is culture from a psychosocial and semantic perspective. It was interesting and he spoke of a thing called “courageous conversations” – you know, all those touchy subjects on elements of our society which if we comment on we’ll be called racist or bigoted or misogynist or otherwise prejudiced. Racism and the history of Australia (or the U.S.A or South Africa or so many other nations) is one of those touchy subjects. So we all listened to the discussion he presented and he played Professor Michael McDaniel’sreconciliation speech and made passing reference to Kevin Rudd’s “Sorry”speech. The things spoken by these two men are along the same vein, but stated quite differently.

On the 13th of February, 2008, Kevin Rudd, the then Prime Minister of Australia gave a speech to acknowledge the past evils that had been afflicted systematically on the indigenous peoples of this nation. The other purpose of the speech was to apologize to aboriginal peoples of past, present, and future who had been (or will be) disadvantaged or hurt as a consequence of the shameful government policies that existed to purposely suppress aboriginal peoples. The speech was symbolic and groundbreaking, intent on paving the way to improving things in future and learning from past mistakes. This very loud gesture was meant to benefit not only the Australian indigenous people who for decades had had their history and rights suppressed, but also of benefit non-indigenous peoples by empowering them with knowledge and freeing them from the guilt of knowing that their ancestors had done something wrong but they now had the chance to right their wrongs. It was by all accounts a very admirable gesture by the leader of a nation.

Professor Michael McDaniel, an aboriginal man who is also Dean of Indigenous education at the University of Western Sydney, also gave a speech related to the reconciliation process that was occurring in Australia. He told one story of a non-indigenous solicitor who met some elders of an indigenous community and tried to tell them that he was aware of the unfairness and mistreatment indigenous peoples had suffered and he had a plan to propose some “reconciliation”, in this case something akin to acknowledging the land rights of the indigenous first occupants of that land. The aboriginal elders when he had finished his courteous and respectful talk, retold him the history of the Aboriginal people. They told him how his ancestors had raped, stolen, killed, desecrated, abused, and hurt their people in previous generations and how the current generation of their people is still suffering because of his people. The young solicitor was taken aback, surprised, and feeling blamed! What do you say to that? You say sorry. And when you say sorry the better man forgives, right? Right. That’s what we do in our culture, but not everyone’s culture is apparently the same in this respect.

Now, I have varying notions of what a sense of responsibility is, but for a while you have to consider yourself in the young solicitor’s shoes also. Prof. McDaniel explains that to the elders they were simply telling their story in their way, that they needed to do this, to vent, if you will. And at that second when the elders meet this young successful non-indigenous man, “For that moment you are Captain Cook. You are Arthur Phillip. You are the Mission Manager. You are the representative of everyone who did those things”. But you may wonder, why should he be designated the “representative of everyone who did these things”? The logic goes that it is because it is as an acknowledgement that the system and society we currently live in was built to ensure the success, exactly as he has, of a non-indigenous person like him and not of an indigenous person like the elders. So is he at fault because he is successful? Prof. McDaniel doesn’t state it quite like this, but he states that the systems that exist are at fault, they’re the “bad” ones. And yet in the middle of all this is a young man trying to do the right thing given what he has. Prof. McDaniel states he just has to “cop it, because it’s part of the healing process”. I know, I was outraged at his logic too. But you know what? Apparently it's hard for us to understand, he says, because (and I am paraphrasing here) ‘as a young non-Indigenous person, we’ve never had a sense of belonging to a society. We’ve never had “a collective sense of responsibility”’.

Honestly, I liked Kevin Rudd’s speech better. I liked it better for two reasons. As a Christian I always remember that scripture in Ezekiel 18:20 that says, “The one who sins is the one who will die. The child will not share the guilt of the parent, nor will the parent share the guilt of the child. The righteousness of the righteous will be credited to them, and the wickedness of the wicked will be charged against them”. Acknowledging our ancestors sins is one thing, we can even apologize for them and regret it on their behalf, but as for being “punished” or held accountable for it, I believe is a bit rich. My second reason can be summarised in this quote by Antoine de Saint-Exupery: “To be a man is to be responsible. It is to feel shame at the sight of what seems to be unmerited misery. It is to take pride in a victory won by one's comrades. It is to feel, when setting one's stone, that one is contributing to the building of the world”. Guilt is a useless thing unless it motivates forward action. It is honourable to take responsibility for righting wrongs even if they weren’t committed by us. It is not honourable to use punishment unless your aim is for retraining. If your camel is already walking to where you want it to go, it is only cruel to continue to beat it.

On skin

I was sitting in with a dermatologist one day learning about skin conditions of the type that are severe enough to make it into hospital. Before I went in to sit with him (as an observer) I had to wait out in the waiting room with his patients. I noticed a red man there with lots of fine scale on his blue work shirt and around his chair. There was also an older lady who I could not discern anything of note from where I was sitting. Then I went in to the dermatologist’s room to sit in the corner as any good medical student.

The man I had seen in the waiting room came in. He was quite animated and greeted both me and the specialist with a handshake and a big smile on his face. He was having another flare up of his psoriasis because he had been working out on a roof (he was a painter, I believe) and didn’t wear his usual long-sleeve shirt that in the Brisbane summer is only best described as torture. He was bright red (beyond what I had learnt the word erythema meant) and was shedding layers of skin everywhere, even as he talked and sat. He had come in his work clothes and he offered to remove it so that I, the medical student, could see and learn just how bad psoriasis can get. He was not a bit embarrassed, and he thought he owed to show me at least the worst spots of the disease, which extended literally from his feet to his face. After his treatment was sorted out and different work strategies were discussed to prevent such frequent exacerbations, he left with a smile even bigger than the one he came in with. The dermatologist explained to me afterwards that he was an extreme example, that he was the worst even he had seen, and that the man was remarkable to continue on with his employment and in such great spirits. I must admit, until that day, I had never even seen any psoriasis at all except in books – and that was not ‘typical’.

The second patient we saw was the other lady I had seen out in the waiting room. She came in, sat down, pulled her skirt up above her knees, and started crying. There were two small psoriatic plaques on her knees, about 4cm long by 1cm wide. The plaques were raised and had some scaly skin on top. There was no redness. This was devastating to her because this was the second or so time this had happened to her in the last four years. One knee, two small spots, and not inflamed. She apologized for having to show us such “disgusting” things that were on her knees; she was clearly embarrassed. The dermatologist treated her as if he had not just seen actually bad psoriasis and tried to dissipate her concerns and offer medical therapy for her skin. I was stunned to see how incredibly emotional she was and how humiliated she seemed to be!

One day I was out walking with a friend and she was telling me how she had always struggled to feel comfortable in her skin because she had a skin condition since she was very young. I had of course noted her skin appearance, but it had never occurred to me that she felt self-conscious about it. She told me how she imagined people thought of her because of her skin. They might think she is unhygienic and her skin is disgusting, that she is ugly and possibly ‘retarded’ or suffering some greater disorder. She said she imagined people would speak of her and comment on how ugly and disgusting she looked, and they would laugh and make fun of her. Just then a group of adolescents with skateboards went past us and were laughing amongst themselves. She said episodes like that made her think it was her they were laughing at. I felt at that moment not pity for her for having a skin condition, but rather offended as a human being not of what she thought people said of her, but what she thought of us, us people other than her.

I had one question to ask her: what did she think when she saw a person with a skin condition like hers? Did she think they were ugly and disgusting? Would she laugh and mock them? She responded no, of course not! I asked her then if she was special, was there something about her that meant she was a good person and the rest of humanity were judgemental, spiteful human beings? She said no, she wasn’t special. Of course she would never think she was special, her problem was one of low self-esteem not a heightened arrogant one! Well, I said, if she is not special and she would never think that way of anyone, what made her think anyone else would think that of her? Here she was accusing strangers, others, of being spiteful, judgmental, arrogant people with vicious mocking thoughts in their minds. Freud called it projecting, the act of ascribing to other attitudes and feelings you personally have. I believe no medical condition, handicap, special ability, money, or other advantage or disadvantage entitles you to cast judgement on other human beings!

There’s an early movie by Pedro Almodóvar called ‘Dark Habits’ in which a group of nuns take on the names such as Sister Manure, Sister Rat, Sister Damned, and Sister Snake. The aim is to humiliate themselves and remind people how even the “good” ones of us are despicable; they believe that “man will not be saved until he realizes he is the most despicable being ever created”. By the end of the film all the nuns have become either prostitutes, drug addicts, drug dealers, and other such “sinners” befitting of their adopted names. At the end, a higher-order cleric visits them to shut their order down and reminds them that sometimes “humility” can be the worst kind of arrogance when you wear it for a badge. Nothing that attracts pity entitles you to act carelessly or exonerates you from being responsible for what you say or do.

On the military and PTSD

There’s something I have wanted to discuss for a little while now but didn’t feel quite ‘qualified’ to. In fact the other reason I hesitated was because I was unsure of my future career direction/choices. It is a comment about the military, or more specifically I should say it is about post-traumatic stress disorder in ex-military persons.

What do I know about the military? Actually, having always been a civilian and having no family members with military or political pursuits, you could say I know nothing about it. Even growing up during the course of a civil war of the kind South and Central America was famous for in the 1980s, my own family was always politically neutral and non-participant. But I admit I do have a very privileged position in my job where people often share with me their stories – and don’t we all have our own war stories to tell!

Now, I won’t violate the trust gifted to me by the men / patients who have told me their stories, but I don’t even need to because the themes of their stories are all so similar. At some point in their journey they have come across me for very simple reasons, for something so banal as to re-prescribe them a certain medication. Usually they will tell me that they have been on some medication for years and just need to continue it, they are content with it, and they need it. And the types of medications they are on are pills for insomnia, for anxiety, to help deal with substance dependency, for depression, for psychosis – essentially medications to help them deal with negative thoughts and noxious mental states. I have previously discussed how men in particular are rarely keen to take psychotropic medications because of some concept of misplaced pride, and yet here I encounter men who are almost desperate to continue on these medications. Do you know what the difference often is? These are men who have seen hell, it lives in their thoughts and memories – they are the men who have been in military combat. These are not weak or desperate men, on the contrary; these are the men every country calls their “heroes”!

Post-Traumatic Stress Disorder (PTSD) is not a new concept nor is it specifically related to military service. Basically it describes a negative mental state that occurs after a person has suffered any traumatic experience. They will often re-experience the negative emotions experienced at the time of the event; often accompanied with vivid recollections of the event itself also. They will feel fear, panic, pain, hypervigilance, etc., exactly as they once did, and often this will be unaffected by the time that has elapsed since the initial event. The initial event can be any traumatic experience, and it is different for each individual with PTSD. Having said that, there are few things in life quite akin to active military service life. And you know what kind of people go into the military? All kinds.

The men I’ve met who tell me their stories almost invariably say ‘I wish I had known’. They wish that someone had told them about the nightmares every night, the hypervigilance and anxiety that denies them enjoying even simple things like just walking down the street without feeling on edge as they once did fearing they would be shot, etc. They wish that someone had told them that joining the military wouldn’t just be a way to secure employment training, to learn self-discipline, to defend and serve one’s country, to procure excitement, or the other variety of reasons a person may join military service. The disenchantment comes when the brave men taking life-and-death risks consider that they were deceived by a sin of omission. And more than disenchantment is the reality that few tasks in this life are as psychologically-endangering as the tasks encountered in warfare.

Of course, the military is possibly the best institution at training personnel in a variety of tasks, and their personnel learn how to “do their jobs” effortlessly. However, how many other jobs are there where you are personally in charge in deciding whether the person standing in front of your weapon will live or die, or that the chances of you killing someone are about the same as those of getting yourself killed, or seeing other human beings (adults, children, civilian, enemies, comrades) been purposely injured with weapons / things that were specifically designed with the intent to harm others? My job is not that stressful; I’d dare say very few other people’s are too. There's no way of estimating which types of events will be psychologically-traumatic to a person - but you can almost be sure that the kind of tasks encountered in military service are quite unique and should at least come with a forewarning.

And that is what these men wish they had been told; that’s why a lot of them become disenfranchised with the whole institution. A lot of these men feel that they have been treated not as men, not as humans, but as “things”, as these commodities that shoot the guns, as if they were merely an extension of the firearms themselves and not human beings with thoughts and emotions and brains that capture moments and memories for years to come. They wish they had known that. It’s a shame we do this to our “heroes”. It’s a shame we feel the need to go to war at all or that those few in charge of making national decisions send others to “represent” them; but if we must fight, I dare to propose that we are at least kind enough to those on our side.

On pride and prejudice... (not the book)

I have previously discussed aspects of the discrimination against people with mental illness. Specifically, I have spoken about it in the context of romantic relationships, how remaining together “in sickness and in health” means in health and in most other illnesses expect psychiatric ones. And of course, intimate relationships are not the only context this occurs in. Even in the health industry there is a deep-seated contempt of those coming into hospital medical departments with wounds that are related to a psychiatric disturbance. But what I find even more bizarre is how people can discriminate against themselves, often denying themselves a better existence, because of a connotation to mental illness!

In my job I meet a lot of people, people who we as medical professional often create. Almost every health professional can tell you a story about “some junkie”, a person with a substance addiction that they met along the way. But there’s a particular sort of person that we at times encounter and we don’t immediately think of as “a junkie” but we know that they’re addicted to prescription medication. In my experience, it’s usually the benzodiazepines class of drugs, the Valium-type medications. There’s a few main reasons why benzos are particularly good to get yourself hooked on: 1) they work, 2) gives you immediate ‘results’, and 3) doctors have fewer qualms about prescribing it than other dependence-forming drugs.

A scenario I see very often, and which I admit frustrates me to my core every time, is the young man coming in to see me for his repeat valium (diazepam) prescription. I ask why he’s on it. He says anxiety. I ask how long he’s been on it. He says years. I ask why. He says for anxiety; it’s really “good” at “treating” it. I ask how much he takes. He takes it “only” 2-3 times a day. I do the sums – he is taking huge amounts of it! I ask why he never had his “anxiety” treated, why he didn’t get proper treatment, why he never had counselling, why he isn’t on more appropriate medication. He says it’s because he doesn’t get “anxiety” that often or that it is not very severe; he only uses the tablets every 5 or 6 of the 7 days in a week, 2-3 times a day.

Usually at this stage my heart sinks because the next part of the conversation is also very predictable. I ask does he know it is very addictive. Yes, he knows, but he only takes it when he needs it, those 2-3 times a day on those 5-6 days a week. Again I ask why he takes it (yes, I always pray the patient will have an epiphany – and no, they never do). He takes it for anxiety, of course. I tell him that it must be pretty devastating to be feeling anxious to the point of needing external relief 2-3 times a day almost everyday; surely that would be very uncomfortable. Yes, he tells me, it is pretty unfortunate – but luckily the drugs are so good at “treating” it that as soon as he takes one, within minutes he feels better. I offer a friendly suggestion: wouldn’t it be better to be able to function without having to feel so anxious almost all the time, wouldn’t it be great to be free of the anxiety? Yes, he concedes. Good, I am relieved he agrees! I say ‘ok, let’s get rid of the anxiety then’ (usually I’ll have figured out by this stage that this guy has no time or patience for psychotherapy, he prefers a pill, even a bandaid if that would do it). I suggest this tablet, you take it only once a day, it’s safe, not addictive, and it has a longer time of action so you need only take it once and you won’t have those flare ups of anxiety at random times during the day or week. He doesn’t believe that’s possible. I assure him, it is; in fact if he takes it everyday he won’t even need the valium for those random daily attacks of anxiety because he just won’t be having them anymore!

He has a question for me now: is the medication I am talking about also called an antidepressant? I say, well, it is an SSRI medication which are classed as such, but has a mode of action that will relieve him of his symptoms. At this point he says No!.. But, but, why? He tells me the story again about his anxiety not being that bad, he doesn’t get the symptoms that often (only 3 times a day, 6 days a week), he’s not depressed, he doesn’t need an antidepressant tablet, he’s not crazy, why change what is working, etc., etc. I explain in vain that what he is taking currently, the valium, isn’t working because if it was he wouldn’t need it everyday, multiple times a day. He assures me it does work, because he takes it and he feels better… and eventually I realize that no-one has ever made a person addicted to a substance rationalise about their dependency. It’s the very nature of addiction, there are no great epiphanies – at least not about why ‘feeling good’ is bad. And it breaks my heart that this person would rather take a tablet with much less stigma amongst prescription pills, almost with the status that alcohol has compared to illegal substances, than take the one he really needs. And he makes his choice because of the association this other medication has to “bad things”: a mental illness such as depression. Apparently it’s a matter of shame to have ANY association to mental illness.

Let me now tell you of another class of patient. He also doesn’t want to be thought of as mentally ill. Luckily for him, he isn’t! He has this condition, a complex pain syndrome, a condition that is very difficult to treat. I met a man once who had been diagnosed as having fibromyalgia. The poor guy, was such a shame to see him; he was in discomfort and pain all the time. He had seen a lot of GPs, a few specialists, spent hundreds on natural remedies and iridologists, spoke to anyone that might be interested and asked for help. Eventually one medical specialist got him started on a medication he hadn’t tried before. He didn’t get his hopes up because he had tried many many medications with no relief. But, amazingly, this one worked! He was free from pain; it’d been months, maybe years since he felt so ‘normal’. And then one day he picked up his tablets from the pharmacy and started to read the consumer information page in the pack. And then he read in there that this drug was a TCA – and that the A in that means antidepressant! He was furious, disgusted, so angry at the doctor that told him to take it. It didn’t matter that the tablet alleviated his symptoms; what was intolerable about it was its name, its association. He stopped taking it immediately and attended his doctor to express his disgust.

I spoke to him a few months afterwards, his face was all cringed and he seemed in a lot of pain. He told me the story of what had happened and about how disgusted he was that the doctor had offended him by giving him an antidepressant for his fibromyalgia. He imagined that the doctor thought he was “crazy”, that he was only pretending to be in pain, etc. I let him speak and then I asked it the medication had worked, though. Yes, he said it had – but that was not the point. My heart again sank a little and I explained to him (gently, not trying to tell him what to do), that the TCA type of drugs are commonly used for some types of pain, and that they are very effective. I said they are called tricyclic antidepressants because their original purpose was to be used as an antidepressant but this new use for them had been found and it was great for pain of that particular sort. Yep, good story, Vanessa; he believed me because he knew I have a medical degree, but pride isn’t always about having rational or accurate information. Poor guy, I still see him in so much pain.

Now I’m going to deflect a little to tell you about something I initially thought about when I was at university. There was a ‘gay rights’ rally and in response to someone’s judgement that homosexuality is a disease and a social evil etc., someone had made a banner saying “homophobia is a disease”. It was like the perfect comeback. Only I’m a nerd who probably overthinks things and I was at the time studying medical microbiology and infectious diseases, so I immediately thought: cancer is a disease too. The point is no-one chooses to suddenly grow a cancer because they want to endanger their life or a limb or organ, or because they like to suffer. Most of us can at least empathize on seeing a person sick with cancer, ravaged either by disease or chemotherapy. I have never met anyone who would discriminate negatively against someone with cancer, someone with a disease they did not ask for, a disease that is beyond their control. Mental illnesses are a disease also, something no-one asks for or can internally control. Why should we accept that it is OK to discriminate against those suffering an illness? It’s sad that almost any reference to mental illness, whether people, disease processes, and even the medications used to treat it, still attract such great discrimination. Maybe the time for a new human rights movement is arriving.

On friendship / giving and receiving

You know what is a good friend? A friend that is always giving (of their time, attention, efforts, etc). You know what is a bad friend? One who always seems to be taking and taking and never giving anything (usually material things) in return. What do you call a person who sometimes gives, but just doesn’t seem to take anything at all from you? I don’t know, but they’re not usually called a friend. 

I used to wonder some time ago why I was never the kind of friend my ‘friends’ called on to help get them out of a tight spot, to lend them money, or just to vent  when everything crashed to pieces. Often I would hear through other mutual friends about how their relationships had broken up, they had won an award, or they’d been in a minor car accident, etc. I was often left with this little numb wondering of ‘why didn’t they tell me?’ or ‘why didn’t they call me?’ And I would feel a little rejected and sad to have been left out of a kind of major life event. I would recede into myself and wonder: 'am I such a bad person that they wouldn’t think to tell me?, to ask for my help?; or do they not like me?, am I considered of no use?' As you can see, I was aiming these comments toward myself mostly rather than the other person. And as I thought about these things, I began to distance myself from these ‘friends’ of mine. I questioned our whole relationship, and the feeling of rejection did not do my self-esteem any good.

Still, I could never figure out why I was never the friend people sought for when people I considered friends needed “a friend”. Until one day I figured it out: I never called any of my alleged friends when things, semi-major events, happened in my life. I either receded into myself and put up the fight (or celebration) on my own, or I spoke only to my mother about it. It wasn’t that I didn’t find my friends worthy of the knowledge or of sharing my victories or defeats, it was more to do with pride, I guess. "You want to have nothing in life that you’re proud of? Let yourself be guided by your pride." Pride is like a fear of falling, so it stops you from reaching too high. Healthy pride, good pride, is probably better called gratitude and self-efficacy. Good pride is an after-the-fact quality; that’s not what I’m talking about. I mean more the pride/fear to be seen as vulnerable, as needing, as wanting, as human. One day I read that to have good friends, you have to be a good friend. I always thought I was a good friend, willing to give to others when they were in need, listening when they needed to be heard, sharing some advice, looking out for their wellbeing, etc. But my friends were never there when I needed something not because they were bad people, but because I was too proud to let them in.

There’s a bible verse that says that there is more happiness in giving than in receiving. Sure, but we all know that there is also something very pleasant in receiving!  That’s right, there is happiness in both. And what any good relationship, any friendship or partnership, needs is both giving and receiving. Sometimes we give our friends a present, something to cheer them up or make them feel good. We feel good in return, right? A happy friend means a happy me, means a healthy relationship. But how about sometime letting our friend also share in the happiness of giving, allowing them give us a gift, being grateful for their effort, validating their efforts and gesture of camaraderie? Of course, I am not talking just about material gifts. I mean allowing ourselves to be human, to admit our need and desire of friendship, of companionship, of another human being to share our load and cheers with. Trust me, if you know anything about human pride, this is actually very hard! We become proud, stern, often as a result of being hurt in the past, or disappointed. We want to convince ourselves and others that we can’t be hurt again. We want to block out the bad – and we end up blocking out the good too. We punish ourselves and others by creating a wall of perceived invincibility. But it’s actually easier to be invincible if you have an army of comrades rather than take the world on by yourself.

So what more can I say to encourage you to be a little more vulnerable, a slightly better friend? You are human, don’t be scared to be mistaken for one. And there’s a paradoxical rule with love: it’s the only known substance that the more of it you give away, the more you end up having.

On labels and self-esteem

I was discussing with a friend of mine one day on how sometimes the worst thing we can do is label ourselves. See, ever since I met my friend she told me she’s a very shy girl – and I guess she is, but it’s not all she is.

Now, the issue of shyness is very close to my heart because I was painfully shy up until the time I started high school. And when I say ‘painfully’, I mean it really did cause me a lot of psychological stress. A lot of people who’ve met me in the last few years would find it hard to believe that I was once a shy person, but anyone from my family could confirm to you how true this is. When I was in primary school (both in Australia and in El Salvador), through every year I progressed, my teachers would speak to my mum to ask why I didn’t interact with any of the other children. I guess the concern was that I was autistic or had some sort of sensory deficit. My mum would explain to them, year after year, that I didn’t have a speech impediment, that I really both understood and spoke the language, and that I could communicate verbally. Academically, I scored at least average grades in classes so at least they didn’t believe I was intellectually impaired, but was always just “something” about me. I knew there was something too, but I knew it was from my extreme shyness. Whenever I did speak, I whispered so that no-one but myself could hear me speak. I was at the same time embarrassed to express myself and embarrassed to be so socially awkward. The solution to this problem was to continue silent.

As I grew older and started high-school I suddenly felt almost compelled to express myself – and in many forms. Some of my classmates whom I’d been to primary school with were absolutely shocked to see me for the first time speak, joke around, and finally have something to contribute verbally. Of course, although it did seem like a magical change in me, I guess I had also just been through puberty and the adolescent psychosocial needs of expression and personal identity were also taking over. I also did not improve in all arenas suddenly, and there are some social spheres I still struggle with, but becoming more self-aware of the problem also enabled me to seek help to improve. As with anyone who speaks of self-improvement will tell you, first you have to believe that you can change (and have the right motivation, and the desire to change, etc. etc.). But therein lies the problem of labelling yourself, because once you label yourself, you adopt the role and you forget that you can change if you’re motivated enough.

We often say "I'm shy" or "I'm depressed" and it's a much heavier statement than saying "I feel anxious in some social situations" or "sometimes I feel very down". The difficulty is that once we label ourselves it becomes a shield to hide behind (and not usually on purpose), that keeps us stagnant. If I start believing that I'm shy (or depressed) and I start describing myself as such, I will start acting like that at all times because that's what I've come to accept is my personality. It's very debilitating to label yourself long-term as anything because it limits your ability to grow. Whereas I could say, “I'm feeling sad right now”, if I say “I'm a depressed person” then I'm not describing a feeling but myself - and human beings don't find it easy to change what is essentially a part of themselves. I think of it as the equivalent as describing your skin colour; that's what our personalities can become if we describe ourselves by our character traits. It becomes as inescapable as our own skin. You soon can't get rid of your "shyness" or your "depression" the same way you can't change your skin. And what's worse is that one day it'll stop bothering us and we'll simply say "I can't and won't be happy because I'm a depressed person" or "I won't meet anyone new because I'm a shy person"...

There’s a speech by Margaret Cho, comedienne, that I’ve included below that describes much better than I ever could the negative consequences of lacking self-esteem, which I guess a big part of shyness is (at least in my experience).

From ‘The Notorious C.H.O.’
I have self-esteem, which is pretty amazing because I am probably someone who wouldn’t necessarily have a lot of self-esteem as I am considered a minority.

And if you are a woman, if you are a person of colour, if you are gay, lesbian, bisexual, transgender; if you are a person of size, if you are person of intelligence, if you are a person of integrity – then you are considered a minority in this world! And it's going to be really hard for us to find messages of self-love and support anywhere, especially women’s and gay men’s culture. It’s all about how you have to look a certain way, or else you're worthless. You know, when you look in the mirror and you think, "Ugh, I'm so fat, I'm so old, I’m so ugly"? Don't you know that's not your authentic self? But that is billions upon billions of dollars of advertising. Magazines, movies, billboards, all geared to make you feel shitty about yourself, so that you will take your hard earned money and spend it at the mall on some turn-around cream that doesn't turn around shit.

When you don’t have self-esteem, you will hesitate before you do anything in your life. You will hesitate to go for the job you really want to go for. You will hesitate to ask for a raise. You will hesitate to call yourself an American. You will hesitate to report a rape. You will hesitate to defend yourself when you are discriminated against because of your race, your sexuality, your size, your gender. You will hesitate to vote. You will hesitate to dream.

For us to have self-esteem is truly an act of revolution, and our revolution is long overdue.

On the human factor... and the risks of work

As anyone who has ever done a job that involves interacting with another human being will tell you, it's often the human factor that ruins most things. In fact it can ruin it so much you can start to lose your will to live. Let me describe one scenario that is all too familiar for anyone who’s ever worked a junior doctor job in a hospital:

Say the procedure is: patient is 1 year old and has a tumour, patient needs pre-op MRI, patient needs surgery, patient then needs post-op MRI. The actual procedure becomes: need to talk to the patient’s parents about the surgery, risks, etc. You then have to organise the pre-op MRI, which is absolutely necessary for surgical planning – and everyone knows this – but either way someone will have a go at you about because you’re requesting it be done today or tomorrow because the surgery is to be done tomorrow and the boss only told you about it today and the patient did not ask for their tumour to be diagnosed only yesterday. Then you have to discuss the case with the anaesthetist who tells you that you need to put an IV cannula in this child before he gets to theatre, although you tell him that the only accessible vein in this child is in his neck and it took another consultant anaesthetist 2 hours to get a cannula in him last time. Somehow, he tells you, the patient’s poor venous access is your fault and you’re incompetent for not being able to cannulate the child. Eventually the kid gets the surgery (after the 2 hours it took the anaesthetist to find a vein in the child) and you have to talk to the parents again because they're worried something went wrong, they think someone somewhere stuffed up and it's someone's fault, and they get all unpleasant towards you even though you're trying to explain to them that their child is just post-op and they'll improve or that it was a risk you had discussed with them previously, etc. Then you try to organise a post-op MRI and the radiologist decides to pick this occasion to tell you how surgical teams do too many scans, that they don't plan them right, that they order unnecessary investigations, that you personally are a crap clinician, that you don't understand how the MRI machine works, that you are wrong and your patient doesn't need the scan... but they'll do it anyway. So by this stage everything that needs getting done IS getting done BUT all these people have in the meantime made you feel so negative about yourself that you start to wonder if it was all worth it. Like, really, why must it be you that cops the abuse? Your role could easily be filled by someone else who knows how to fill in the forms and talk to people (aka the majority of the tasks the junior doctor job actually involves). So why must it be you? Why? Seriously. Hopefully the kid gets better, and maybe you had something to do with it, but you'll never think of it that way, and the family or the patient will never thank you, so all you remember from the interaction is the abuse everyone laid on you and how small you felt afterwards. Was it worth it? Was removing that child's tumour worth you self-esteem? Was it worth losing your self-worth? Was it worth losing your passion for your job, the big picture? And maybe, just in some, the question becomes ‘was it worth losing your will to live’?

Okay, so maybe the final statement was a bit of an exaggeration but it is not describing a new phenomenon. I always remember that story from ‘House of God’ about the medical intern that suicides and how every year a certain percentage of doctors do. But the phenomenon, of course, isn’t limited to health professionals. Cliff Baxter, one of the executives of Enron Corporation (the U.S. energy company that went bust in 2001), suicided after he was indicted to court for his role in the Enron bankruptcy case. In his suicide letter he wrote, “where there was once great pride, now it’s gone”. As an executive of a corporation like Enron was, Cliff Baxter wasn’t a weak or stupid man, but to me at least, his story warns about the risk of defining yourself by your job. I find it sad to think that having a wife and children, he saw his life as not worth living because he could no longer live with pride for his work. What about living for his wife or his child? What about living because there are other things in life besides work? I can’t help but feel that if you have to rely on your job to make you feel satisfied, to make your life feel like it is worth living, to make you happy, then you’re probably lacking something very important and beautiful in your life.

They say that doctors are especially prone to what is commonly called “burnout”, in general, for the same reasons that they have chosen to become doctors: they are often perfectionists and have a high sense of responsibility. In the workplace these are exactly the things patients and their relatives appreciate and expect. Other co-workers also expect the same thing from them. And what’s more, eventually the doctor comes to expect this of himself. So then he starts going home late to make sure everything is OK (a.k.a. “stable”) before he leaves. He’ll work all the ridiculous shifts and hours he is told to because he’s expected to and no-one before him has been able to change the system so he just has to submit. Of course, with all the time (and let’s not forget effort) dedicated to work and career progression, he spends less and less time with family, socializing, relaxing, and essentially doing all those things that truly enrich human life. It’s then easy to imagine how with work consuming so much of your life, a person could come to define themselves solely by their work. You start to associate success exclusively with occupational achievements and less with the attainment of personal, family, or social goals. Proverbially, you come to ‘live to work’ not ‘work to live’. And once you come to do that, it is not so far-fetched to imagine guys like Cliff Baxter who, having lost his ability to work, come to believe that he has also lost the ability to live.