On insight

When I was younger a psychologist once asked me why I always ended up in relationships with people who were 'unavailable'. Of course, she asked me this rhetorically to prompt me to reflect on the pattern of my relationships. She asked if I could remember the first time someone had made me feel like I was vying for their attention and yet I wasn't getting my emotional needs met consistently. Yes, how cliché, it was with my mother as a child! Now, what most people instinctively do when we find a source to our problems is it either 1) brings us comfort by allowing us to say "hey, it's not my fault I'm like this", or 2)  we feel guilty that we are the way we are. The problem with blaming the past, though, is it's of no use to anyone if it doesn't force change.

If we feel guilt (which is an unpleasant emotion and thus makes for a great self-flagellation device), we come to believe that feeling guilty is exoneration enough for doing what we do. But if feeling guilty is ALL we do, we usually just continue to behave in the emotionally-immature coping patterns we're used to. It's not enough to feel guilty. It's not enough to wait passively for things to change. In real life, the poor little victim princess doesn't magically get rescued by a hero. In real life the princess needs to build up her strength, overcome her own past, and slay her own dragons in order for things to change for her. It's not a matter of 'good things happen to those that wait', but rather good things happen to those who make things change.

On my religious and spiritual journey - Part 3/3

When I started re-evaluating my concept of God and what his will was, I went back to basics. I remembered a scripture in the bible of when Jesus was explaining the purpose of what Mosaic law meant. The law given to Moses had hundreds of commandments of what the Jews had to do and not to and when, etc. The purpose of it all was to ensure that the Jews worshipped God in a certain manner and also that they be protected from harm. Then Jesus implied that after his death, Mosaic law was to be abolished and he said that the whole of God's will can be summarized in only two commandments (not the hundreds given to Moses): 1) Love only God as god, and 2) Love each other as God loves you. That was it.

I concluded that God's will had nothing to do with guilt, and guilt was not a virtue to God! Sure, the bible still has those commandments about how to practice his worship and no idolatry, no fornication, etc, but also it tells me that God does not ask of me any more than I can give and that He will be the only one to judge my sins, errors, behaviors etc. I am not God; I have no place trying to judge other's sins or punishing myself for my own. God who knows what is in my heart, my intentions, why I do the things I do, why I desire the things I do, I believe is the only person fit to pass judgement on me. And that is my "new" thinking. That is how I came to stop feeling depressed about having to make religious sacrifice and how I overcame my guilt for just being human. If I had to do it all over again, I don't think I'd pick a different faith, I'd hope I just merely came to this conclusion faster.

So what is my philosophy? As I’ve discussed previously, my personal values are my family, participating in and enjoying life while I am alive, and not making a world a worse place for anyone or anything. I believe in God, but I also believe in humanity. I believe human's greatest quality is our ability to think and reason for ourselves. I sometimes meet with a religious group whose ideology I mostly share and I call myself a Christian because I do believe in the Bible being a holy book and I aim to follow the guidance provided in it by Jesus Christ. I worship God because I am grateful to him for all I believe he has been responsible in my life. I follow the things the Bible says because I believe it is wise and its mandates are for my overall good. I’m not scared of God that he will punish me in any way because the God I believe in is understanding, merciful, forgiving, and not vengeful. I believe he is far too grand to be offended or hurt by the actions, words, or thoughts of one little person as I am. I understand also that my belief in God may be mythical, as real as he feels to me. So I hold nothing back from this life that I may experience it in an afterlife that I am not 100% guaranteed will actually happen. Once upon a time perhaps my faith was stronger, but for now this is the God and the rules and the values I believe in. This is the type of God I respect, and the type of God I want to emulate.

I love God. My God. I love the type of God that lets me love him and not at the exclusion of also loving myself.

On my religious and spiritual journey - Part 2/3

If it weren't because of the lack of contact with other believers and an ever deeper instruction in them, I would have joined a Jewish or Buddhist religious organization. I did wish that Judaism had reached out to me further rather than feeling that it was not a religion that encouraged new members from other cultures/ethnic group. So I delved further into going with what was around me, which was for a long time was only Catholicism. I asked a lot of questions and mostly I was shut down because, I was told, some things I just had to accept and believe rather than understand.

Only one religious group welcomed my questions and actively sought to reason with me using a holy book (the bible), "logical" deduction methodology, and my own knowledge of the world and science, etc. This group's philosophy and people welcomed me and I welcomed all their doctrines into my life too. The fact that I welcomed it too shaped the next few years of my life. Many of these group's ideals had been my pre-existing ideals also so that certainly helped to adopt this new religion. It interpreted the bible's New and Old Testaments largely literally - and it even tried to show with historical and scientific correlation how this text / prophecy was a true document that should inspire my belief and obedience. And I still to this day believe it is so, either in spite of or because of my academic background in science.

I came to believe that the bible was a document worthy of my respect and belief, and I believed then that I must do the things it says that I do and don't do in this life. Obeying bible advice was at times instinctive, but often contradictory to what I wanted and desired. No other aspect I think was more pronounced for me than its concept of "fornication" or sex outside of a traditional marriage. That was certainly not instinctive! Yet for very many years I bared my stake/cross and sacrificed my desire for sexual intimacy for the sake of not displeasing the God I had learnt about in the bible. I still don't feel that this sacrifice was in vain or bear resentment of it, but rather I am still proud (and amazed) that I was capable of such dedication, commitment, and self-control for all those many years.

If you asked my why I joined the religion I did (and I'm not talking about Catholicism, which I inherited and never chose), I would say it was because it was the one that to me seemed to have a concept of God and practice that I thought would most resemble a God that I could respect. This God (and this religion) encouraged my questions and helped me find the answers in a book believed to be inspired by God. He was also a God that had many good qualities, that encouraged new followers, and that gave commandments that were meant to benefit me and not merely fill me with guilt. I liked this God, and I liked what he stood for.

Over time I found myself becoming more and more unhappy, depressed, feeling guilty all the time. This was because I was finding it increasingly harder to do what God asked of me and it was really weighing me down. The more I tried to be a good Christian, the more it hurt. I became depressed. There were many reasons that culminated in my depression, but my spiritual beliefs should have been my saviour not the lead weighing me down further. Then I finally put the pieces together to my inescapable depression: one of the main characteristics of depression is undue guilt; and yet one of the tenets/virtues of Christianity is to feel guilt!

In Christianity it is believed that Adam and Eve were guilty of the the original sin (disobedience) and from them all human beings have inherited both the tendency to sin and guilt for this sin of theirs. Do you know how hard it is to overcome depression when you continue to feel guilty? I can see the futility of my thinking now, but for a long time I had no idea why so many of my other co-worshippers were suffering depression too. Guilt will eat you alive! Now, I'm certainly not saying that all cases of depression are due to undue religious guilt, but taking to this concept of Christianity as passionately as I once did does push you further down into a black hole. Luckily, I did not stop learning or thirsting for more knowledge and wisdom once I had become a full member of my new religion.

On my religious and spiritual journey - Part 1/3

I was baptized as a baby into the Catholic Church. This was not my mum's idea and nor did it actually signify anything as to what my life would be as it was purely done out of cultural and family tradition. Growing up my mum taught my siblings and I to be respectful of others, not hurt them physically or verbally, to be respectful of the law, and basically to treat all human beings as equal and as we wanted to be treated in return. She also taught us about this spiritual being called God that we could never see or hear but that we could talk to in prayer to ask for help and guidance in our lives. She taught us about this book called the bible that had all these stories about God and things he had done for other people who were "good" and others who were "bad". As a result of that I concluded that I wanted to be "good" to please this God being and have his blessing and not upset him and have his punishment in the future, which mostly meant after I was dead. She didn't teach us religious rituals or ritualistic prayers like those practiced in the Catholic Church as she herself did not believe they served any purpose.

When I was seven or eight it was decided that it would be nice for me to get to wear a pretty dress, like other girls in our town did, and partake in Catholic communion. Like my baptism as a baby, it was more about tradition than any religious or spiritual symbolism. A few kids and I met for a few weeks with a very nice and respectable member of the church to learn from an illustrated book about Catholic rituals and a bit more about the stories in the bible about angels, Jesus, his mother Mary, and also about how the communion ceremony would proceed in a few weeks. We rehearsed the ceremony and learnt some Catholic prayers and hymns. My mum had a really pretty white dress prepared for me. I still remember some of the songs we sung and the part of the communion ceremony where I forgot everything we had rehearsed for it, specially of what I was supposed to say to the priest the first time I took the Eucharist and he said something about the "body of Christ". I was completely blank standing in front of him and wondering what I was supposed to say back to him so that he would give me that sticky wafer. I remember he kept asking me over and over again, changing the intonation of his voice to a slightly more angry one, and I couldn't think of anything to say back to him. At one point he inflected his voice to sound like it was a question "body of Christ?" and I thought I had finally figured out the answer. "Yes", I said. No, he repeated it again and then asked if I didn't know how to answer properly. I said, "Yes, please". Finally a child standing behind me in line said to me "you have to say Amen". Finally I said it and the priest gave me the Eucharist, but before I walked away he asked who my communion teacher had been. I can laugh at it now but for years I felt guilty that I had gotten Cesar, my teacher, into trouble by forgetting the word "Amen". (Guilt, mea culpa, and penance were some of the catholic "traditions" of christianity that Cesar had also taught me.) At the end of it all, everyone commented on how pretty I looked in my communion dress, and that to myself and my family is all Catholic communion meant: a chance to wear a pretty dress in front of a lot of people. My baptism had been my grandmother's idea (my mother thought it was a waste of time because I was a baby and I would have had no idea about Christianity), and my communion was town tradition mixed in with vanity.

I completed my Catholic "confirmation" when I was about 10 years old or so. This time it was one my aunt's idea for whatever reason that one my brothers, her son, and I all partake in this ceremony. Again, I had to go to catholic Sunday school for a few weeks. We learnt from another illustrated book about angels, catholic rituals, and Jesus. The book was very colorful and I liked the drawings in it. We also had to go to confession where you'd tell the priest bad stuff you've done and, as if he was some sort of authority, he told you that God would forgive you if you repeated some ritualized prayers so many times. I hated going to it as I had to think for ages on what I could possibly have to feel guilty about at 10 or 11 years old so I could feed to the priest at confession. After some weeks, the communion ceremony was held and we got given little certificates, a little badge with a dove on it, and we took heaps of photos in our nice clothes. Our school principal was at the ceremony and participated in it, which I didn't like because he was very mean to everyone at school and often hit the boys' hands (and once mine also) with a wooden ruler for misbehaving. I thought he was a hypocrite and not a good person, even though he was apparently a good Christian. I knew, though, even at an early age, based on what mum and not any of my Catholic teachers had taught me, that it was not my place to judge him.

After arriving in Australia, I attended a catholic primary school (with the principal I spoke about) and then a catholic high school. High school for me was such a massive change from what I had been in primary school. I finally got over my shyness and I started to form my own ideas about life, etc. As any other teenage kid, I started challenging my superiors and rebelling just for the sake of rebelling. At school I wanted to challenge my religion teacher's doctrine, and at home I wanted to challenge mum's. My mum had started to become involved with a Christian group that went very much against idolatry and religious rituals. I began to wear a crucifix I was given at school as a necklace to irritate her. At school, I would question my religion teacher about some of the scriptures I'd overhead mum learning about at her home bible study and other things I had learn at Catholic Church too. I asked my teacher about worshipping a cross or a manmade icon when God had strictly forbidden such behaviour to the Israelites in what is commonly called "the Ten Commandments", or why I had to call the priest "Father" when Jesus had insisted that not even he (allegedly God's son) be called this let alone any other human being, or why had to talk to the priest to ask for forgiveness and not directly to God if God allegedly loved me and was all-powerful and so should be able to hear my prayer directly, etc. etc. I admit most of the time I was just trying to stir people, my religion teachers or my mum and her friends from her new Christian group, but underneath it all, I guess I was also curious about religion and spirituality. Gradually I started to become more and more interested in theology.

By the time I was 17 I was very much into reading about different religions and theological belief systems. I found Christianity particularly fascinating in that so many hundreds of denominations exist with slightly (or very) different focuses, practices or rituals, and interpretations of what is essentially the same story in one book. The common origin of Judaism, Islam, and Christianity seemed so enthralling to me. The more human-oriented philosophy of Buddhism and Eastern traditions inspired me to wonder more about what is "humanity" in humans. And the polytheist religions both inspired disbelief (because it was so foreign to all I'd ever learnt with only one God) and curiosity as to how models of religion and spirituality are constructed by the minds of human beings. By the end of my schooling and soon after starting university, I was sure I'd one day I'd either join Judaism or Buddhism. I was a lot more preoccupied with religion in my teenage years than in what other teenagers were interested in; yet not completely. Sex interested me. It interested me in the normal way, and it interested me in the way it was so closely related to spirituality in most religions.

On me... and turning 30

It’s funny, if you ask some people who have really gotten to know me intimately they’ll tell you that I have several different personalities. These people have at times asked me who is the “real” Vanessa. I can tell you straight out that ALL of them are. If you’d met me some years ago and asked me to list the things that to me are the most important in life I would have told you: family, love, expression, enjoyment, spirituality, and work. If you met me at another point in my life I would have answered exactly the same thing – but in a different order! That is where my “inconsistencies” lie, but actually I am just very average J

The self-hating years

The single most hurtful thing ever said to me was “you’ve had a perfect life”. Yeah, it was hurtful because it was said by someone close to me who obviously didn’t know me much at all. I don’t believe there are such things as perfect lives or perfect childhoods, everyone does the best with what they’re given. I don’t know if I am (or was?) autistic to a degree, but I never really connected with anyone as a child. And it didn’t bother me to have no friends; I was quite happy in my own inner world, my make-believe play, and reading books to learn something that interested me. At age 10 I was faced with circumstances that are actually very common in most cultures but that I would never wish upon anyone. As a result of this I lost the ability to trust, to believe, to feel safe and worthwhile. From then on I started hating more than just my own physical self, but also my future self, believing that I deserved nothing good to ever come to me in my life. It was very draining, and my inner world grew increasingly darker and I became more and more self-deprecating.

At about the age of 20, after I had finished my undergraduate degree in science, the self-loathing and self-denial of my own need to be human finally climaxed. I started psychotherapy for the first time then. What came of it? My single greatest victory was to forgive those that had hurt me and to forgive myself for being hurt. It seems so miniscule and meaningless that I can summarise it in one sentence, but the amount of healing the simple act of swapping the words “sorry” for “thank you” is hardly able to be explained. I finally stopped apologising for being Vanessa, for allowing myself as a child to be hurt, and I stopped apologising for the simple fact of being alive. Instead I started to be grateful to be alive and I allowed myself to have (and not feel guilty about having) human needs of personal fulfilment and achievement. It was a very slow process to accept myself, to disrobe myself of the self-loathing, to finally become and be comfortable in being Vanessa in all my forms.

At 24 my curiosity and interest in spiritual matters brought me to commit to Christianity after having studied several theological and philosophical systems for many years. What lead me to finally make this commitment was that I came to understand that it’s ok to not be perfect, it’s human nature, and that the ability to feel connection to God is not barred to me or anyone else regardless of their past, present, or future. That was spiritual commitment and to some extent also fulfilment. During and after this time I also gradually learnt to not hate or feel ashamed of my physical appearance, of my lack of social skills, of my naivety, and of all these things I had for which I felt I couldn’t be like “normal” people. I guess in all this I may have eventually overshot the mark  :P

The self-loving years

I was around 26 before I could bear the thought of being ok with being seeing as me, as a complete and separate person of my own. I guess by that stage I had allowed people to get to know me, all aspects of me, and to become my friends who I could trust and expect some trust and caring in return. I grew more confident in many things also. I finally was not afraid or concerned to be seen for me. I was nearly 27 before I finally allowed myself to remove my clothes off in front of another human being – someone of my choosing and with my full consent. This part was the hardest step for me, the rest was quite easy. And in fact it probably got to be a bit too easy J

My mistake was that after I learnt to love myself, I probably started to love only myself. I started to consider romantic partners as purely things to increase my own enjoyment and happiness. They say that people with histories of abuse most often become either one of two things in their future relationships: the abuser or the abused. I had decided from when I was 20 and started therapy, that I would never again be a victim of abuse. And so here I was, playing out another role. I had never had a time in my life when I didn’t feel guilty about being alive, but maybe at times it would have been good to at least feel pity for others. Needless to say, several  partners later, I still wasn’t a winner. Despite me finally being able to love myself and form sort of bonds with others, I still hadn’t learnt what it was like to love others. I mean, of course, what it was like to be in love.

The loving years

Wait, having sex and making love aren’t the same things?... No. I eventually learnt that too. June 2010, or sometime after that, I fell in love for the first time in my life! How did I know it was different? Because I found myself missing someone else, wanting someone else’s approval, feeling safe and confident to be associated with someone, feeling a part of something very special. It didn’t last long and I was a different kind of sad to what I’d previously known when it ended. But you know what bothered me most about it ending? Because after all those years it had taken me to convince myself that I was a worthy human being, the overwhelming message I was getting was that I wasn’t worthy of another being’s sacrifice to be with me. My partner wouldn’t sacrifice any of the things I would have sacrificed in a heartbeat to be with them. And that hurt me so much. It was like being told all over again that I wasn’t a worthy human being. But this time I didn’t believe it for long, because sometimes all you can do is let go and remember that regardless of what someone may think of me, I am still Vanessa.

And then the unthinkable happened and I fell in love for the second time in my life. Wow! What a blessing it was. It was beyond what I had ever imagined;  my new love met and exceeded every standard I ever had. This was truly the love of my life, the one person you could have sworn was fabricated purely using every guideline for a good person I had in my mind. Words can’t do this story justice. Of course, I was in love with this person so you’d be right in saying I am biased, but I didn’t care what anyone had to say. The only approval I needed in this world was from this one person . Truly, never have I felt so secure, so safe, so myself, so part of something greater than special, than when I was part of this partnership. Then the worst thing happened! The worst thing to have happened to me at this moment in time after what I’ve been through, I mean. There were reasons for it, but I was left alone again. I only wish I had been given a chance to correct my flaws, that whatever good was at first seen in me (what I think I see in myself too) would have been worthy of another chance, of a sacrifice. Or am I really not as worthy as I think I am?

The years of being loved

I hope in future to be loved, but it’s not enough just to be loved here and now. I hope to have someone fall in love with me truly, to want me, to wish to be with me, and that this wish is enough to motivate the things every successful relationship needs: compromise and self-sacrifice. I am worth it, right? I think I am. It’s been 30 years, and I’m ready to be loved the way I eventually learnt to love too. I am ready for so many things. But I am ready mostly to say that only God can judge me for my life.

On telling

I remember as a medical student being told by a psychiatrist who was teaching us about clinical communication skills to always ask yourself “is this for the patient or for me?” A little bit of self-disclosure in clinical scenarios is helpful; it helps establish rapport, trust, and confidence that the person we have entrusted with our psychological care knows exactly what it’s like to be human. That’s the purpose of self-disclosure in medicine, that’s how we can justify telling patients our sins, our glories, and just our everyday occurrences. Besides that, all we are being paid to do is provide a clinical service of diagnosis and treatment. Needless to say, it’s not appropriate to start telling our patients intimate details about our personal lives and thus introduce potentially biasing information that will impact on the patient themselves or their views on us as their clinician or the clinical advise/treatment we provide. But this rule about what we tell and don’t tell got me to thinking to how it applies to life in general, not just as it applies to health professionals.

Two key features of a successful and happy relationship are honesty and trust. You want to be able to trust that your spouse/partner/friend/business associate/etc. is an honest person that does not lie or betray you, right? But at the same time you need to be able to trust that they won’t, otherwise the relationship will be ruined by the constant questioning of their (or your) honesty. Consider, for example, an ideal romantic partnership where the two people involved love and care for each other and have romantic interactions exclusively with each other (including sex, but also other forms of physical or psychological intimacy). That would be a good relationship, right? But what if a similar scenario arose where the two people involved in a romantic partnership love and care for each other and have romantic interactions exclusively with each other BUT the partners were repeatedly asking of the other: “have you slept with anyone else today?”, “have you told any lies to me today?”, “do you love me still today?”, etc. etc. Now, the other partner could repeatedly be honest and say “No”, but isn’t it likely that this good and honest relationship will be destroyed by the lack of trust?

Now consider a scenario where you have the trust but not so much the honesty. You could, for example, have two people who love and care for each other but their romantic interactions are not exclusive to each other. They may every once in a while have sex with other people. They don’t, however, ask of each questions of fidelity, it is only assumed – they assume the other person is honest or sexually monogamous or that they have romantic feelings only for them. You could say that these are either happy human beings or you could say that this is not a good relationship, even if the two parties seem outwardly happy with themselves and each other. You may say that even if everyone it is happy then that happiness is invalid because it is predicated on dishonesty – or better said: lack of honesty.

This ‘happy couple’ to me poses a very interesting human dynamic, because as happy as the members of this couple are and as happy as the whole scenario is, it often fails. And it doesn’t fail because of dishonesty or mistrust. No, it fails, because of misplaced and selfish honesty. Again, let me repeat the scenario. There are two people who love and care for each other and are not unhappy in their relationship, but one (or both) of them engages in an act of intimacy (however you wish to define it) with another person (or persons). They’re not unhappy with each other, their relationship works and is otherwise normal. The relationship can function this way for months, years, decades, or until death parts them. What’s wrong with that? What’s wrong with having a happy life and a happy relationship, right? Well, probably nothing, except that it rarely happens. And I’ll tell you why.

After one of the members of a partnership has committed an indiscretion to whatever gravity, something happens but not to the partner who may be blissfully unaware or to the relationship which still has as much potential as it did before, but something happens to the offending partner. You know what it is? Guilt. Guilt creeps in, escalates by the minute, and this thing we call a conscience tell us that we should tell our partner what we did. It goes over and over in your mind, you convince yourself you are a bad person, you are convinced what you did was wrong, but overwhelming the feeling is guilt. Tony Robbins once said that guilt is really a trigger to correct your behavior, it means you have a standard which you haven’t met and as a result of this failure you feel guilt. That’s the point of it, to correct behavior back to what your standard is.

The truth is most of us do sign up to relationships to be an exclusive intimate partnership between only two people; that’s our standard. That’s what we expect to receive and that is what we expect to give in the partnership. So when we fail, when we don’t reach our own standard, we feel guilty. But what a lot of people do is mistake the trigger to change our behavior for one of simply anxiety or an unpleasant sensation. Therefore instead of thinking that what we need to do is change the behavior, we become convinced all we need to is just to relieve the guilt. So maybe we’ve stopped doing what we once did that caused us to feel guilty initially but we continue to experience the guilt because we can’t forgive ourselves. And we’ll keep feeling guilty until the day we decide to do two things: 1) meet our own standards, and 2) forgive ourselves. The second part is actually a lot more difficult than the first one is, so we often – mistakenly – substitute it. You know what we do when we can’t forgive ourselves? We ask others to forgive us.

When you can’t forgive yourself for cheating in a relationship, even if it was a once-off, we often make the mistake of asking our partners to forgive us. And we ask not because we care about them or because we love them and think they deserve to know the truth. No, I don’t believe that at all (although that is what we tell ourselves and our partner)! We tell of our indiscretions purely as a selfish way to ease our anxiety and guilt. This is what I mean by selfish honesty. There is nothing honorable about wiping your filthy hands on someone else just because you want to have clean hands again. That is selfish, self-indulgent, and spiteful. Don’t get me wrong, though, there are cases when we must confess to our indiscretions, such as, if we have placed another person’s health at risk or there are legal ramifications to our acts, etc. And here is where we need to ask ourselves: “is this for the other person or for me?” What exactly do you expect to gain?

If we tell our stories purely to ease your guilt, then don’t expect a reward for your honesty. I think that is so banal. Yet that is often what a lot of people do, confess their “sins” to their partner, tell them that they are confessing because they didn’t want to lie to them anymore (even though they had caused the other person no harm at all), and then expect to be forgiven because that is exactly what they need to ease their guilt. That is an even greater violation to the relationship. We shouldn’t use our partners to wipe our conscience. If the anxiety of holding a secret is really tearing us apart, if the guilt of what we’ve done is eating us away, there are more responsible ways to deal with it. As I said, what you really need to do is change your behavior. And if you must tell, tell a friend or pastor or psychotherapist, etc. The only reason we should tell our partners - hurt our partners, their self-esteem, their self-worth, their trust, their sense of identity, their faith in you – is to benefit them, not selfishly ease our conscience. And then we must expect not forgiveness but consequence. 

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 prescribing choice... and the hypocrite's spiel

There are many people who will tell you that pharmaceutical companies are the devil. I say the devil is the devil, but I also say the pharmaceutical companies are no angels. Let me first disclose something to you: I eat the lunches brought in by the pharmaceutical sales representatives (almost everyday at my work!), I give my patient’s their drug samples, I enjoy their “educational” dinners at expensive restaurants, I am grateful at their supply of products ‘directly related to my clinical practice’, and I miss the days of the free drug-stamped stationery and random gifts. I do not claim to be immune to their marketing tactics simply because I am aware of them; both they and I know that I am human and the tactics exist because they do work. There are those who directly embrace the drug companies with the attitude of ‘hey, if they want to give money away, they may as well give it to me and I will do what they want me to do’. And there are those that completely shun them, who demonize them, who accuse them of being a… a business. Aren’t we all in business? Those who claim they aren’t, aren't in business very long.

Just this past week I recognized a tactic by the sales reps I hadn’t noticed before: bullying. Now, what I mean to say is not that they wanted to humiliate or hurt me, but they sure as hell wanted to make me feel guilt. Now if I remember correctly from my industrial psychology and marketing readings, creating negative emotions in targets is one of the least effective methods to inspire change of behaviour (in this case, prescribing more of the drug they’re promoting); however, least effective doesn’t mean ineffective. The rep was telling me of some new medication; was I using it, she wanted to know? I said no, I studied a little pharmacology too and I felt more comfortable with another medication. She was horrified! Did I not know that it was the most popularly prescribed medication in its class, prescribed by the greater majority of my peers?! My mind was thinking ‘yes, and?’, but I said, ‘Oh, ok. I’ll keep that in mind. Anyways, thanks for the lunch.’ I went away thinking, wow, really, everyone but me uses it, was she implying that I am doing the wrong thing by prescribing something other than “the most popular”? Is it the most popular because it’s the most effective, because it the newest (and newest we are told is better), because they are better doctors than me and if I want to be good then I must be like them. As I walked towards my consulting room from the lunch room where I had the food brought in by the friendly drug rep, I realised it had worked. I was here second-guessing my clinical management not based on clinical data or evidence, but based on simple human emotion: everyone likes to be liked and to be like the rest. I then laughed at myself.

A few weeks ago another drug sales rep was speaking of a medication for erectile dysfunction. Of course it was about the drug, but they alway tells everyone “it’s about the patient”, thinking of what’s best for them. There’s no news or controversy in saying this; no matter what industry you work in, at the end of the day everyone must eat (and you need money to buy food, right?). Every drug rep walks in to that lunch room and comes with 1) our daily bread (or gourmet lunch), and 2) the “educational material” to impart to us that just so happens to show that the drug their company sells is better for our patients for some or another important reason. But this drug rep wanted not to tell me about why their erectile dysfunction drug was better than the other two, but wanted to know what I based my choice on. I’ll tell you what I answered but first I just want to consider another point on prescribing choice.

Now, you could have five different drug reps talk to you about five different drugs from the same class, both targeting the same “disease” (I’ll explain later why a disease is worthy of my quotation marks here), and they can all show you with ‘real clinical evidence’ and ‘scientific studies’ that their company’s drug is the best. The first rep will say their antihypertensive is the best because it, say, doesn’t have this bad side effect. The second one says theirs is better because it reduces blood pressure quicker than the others. The third one says theirs is better because the effects on reducing blood pressure last longer. The fourth one says it their drug tastes better and is in a smaller pill and that this is very important to patient compliance, therefore in fact being the best drug because patients will actually take it. The fifth one will say theirs is the newest and is so many times better than a placebo. Who wants to be associated with the old and outdated, right? Ah, the stories…

What I answered my friendly drug rep is actually not anything new to them. Why do I prescribe a certain erectile dysfunction drug versus another? Honestly, I confessed, my choice was based on whatever sample pack was in stock in our drug samples cupboard. They know this, that’s why they like to stock our cupboard, not because they like to give away “free samples”, but because it works at securing consumers. I have to clarify a little, though, I use this rather non-clinical method to guide my prescription choice only in certain conditions that in my experience the medications are only slight variations on each other with similar clinical effects, for example as in erectile dysfunction. The second reason to why I do this is because these medications are very expensive and I want my patient to try it first before he goes and spends his hard-earned money on something that may or may not be right for him. Most doctors do this, too. You give the patient the sample pack and a script to purchase the medication if they are satisfied with the effect or tolerant of its side-effects. In cases like this, I prescribe what is in the drug cupboard because I know the brand name will make little difference to the clinical effect I am trying to achieve in a patient. For some reason my honesty seemed to surprise the rep and I think it is because there must be some secret pact that we, both the pharmaceutical companies and doctors, must deny that our interactions are in fact business transactions and we should pretend they are purely “educational” and clinical.

As a medical student I did a placement at a clinic that strictly forbade pharmaceutical reps from visiting to promote their products (or should I say, educate us). It was a clinic were most of the clinicians also held academic posts at the university and they were thoroughly involved in evidence-based medicine. I remember one doctor specifically telling me about how he always prescribed the generic version of a particular drug because it was the cheapest and therefore it meant less money spent on government subsidies paid to the drug companies, and subsequently more money left in the health budget for other essential matters. It made sense to me.  Some years later I worked at another clinic where another very noble and more senior doctor advised me that I should prescribed the brand-specific version of a medication for depression that was now off patent. The reasoning was that the company that made this brand of antidepressant was highly involved in drug research and development and also at producing patient education and support materials, but they obviously can’t afford to do that unless they are making money also. It made sense. Yes, besides I also knew that once you allow for the generic version of a medication to be dispensed by the pharmacist, he incidentally happens to supply the patient by the generic version of a medication which is made by his pharmacy chain. Oh, everybody is a businessman. So my choice is then, who do I feed? The pharmaceutical company making the brand-label stuff or the pharmacy chain making the exact same but generic-labelled stuff (which in most cases cost no different to the brand-label medication). Ah, such decisions… Oh yeah, that’s right, this was mean to be about the patient!

Another thing that the pharmaceutical companies are accused of is not only of making healthcare a business (which I don’t believe they are solely responsible for), but of also creating disease. What do I mean ‘creating’? This is mostly in reference to the medicalization, the labelling, of certain human existential states as disease. Some years ago I read a story about how bad it apparently is that we have made things like pregnancy and ageing disease-states. In a similar vein, drug companies have been accused of doing either a good or bad thing, depending on your point of view. One could say that thanks to the educational and public awareness campaigns directed by our blessed pharmaceutical industry, so many people can be diagnosed and directed towards the treatment of many ails such as depression, anxiety, mood swings, hyperactivity, etc. etc. Another group of people report that the drug companies directed these campaigns as a diversion to their real campaign: increase uptake of certain medications (mostly psychotropic medications). They convinced people that their sadness, that their agitation and worry, that their child’s childish behaviour, are abnormal and required treatment – by using the drug that their company so happened to manufacture. Oh, so many coincidences…

And what have I achieved in telling you of these few tales? That I am a hypocrite? Maybe. But hopefully I have also reminded us all that we live in a capitalist society and that denying that there is a devil at our table won’t make that devil any more of a saint. Worse than being the devil’s pawn is not knowing that you are. As doctors, as human beings entrusted with the care of others weakened by disease, we must ensure that that truly is the worst thing: that we sell our own souls, and not that we trade in those of our patients for a piece of the devil’s share.

On "that" year

Kingaroy, QLD

2006. I was 24 still. I was a child still. But before I tell you about that year, I’ll give you a speedy run-down on my life until then. Age -9 months: my mummy meets my daddy. Age -6 months: my mummy finds out the father of her daughter is also father to 14 other children before her. Ages 0-9 years: growing up in El Salvador, a country with low literacy amongst those of my social class, and in a single-parent family where no-one has ever finished high school even. Age 6: I “decide” to become a doctor like the “cool” guy my mum works for as a cleaner/nurse. Ages 6-22: still stubborn about wanting to be like that cool guy. Age 23: finally start medical school. Ages 23-24: study, study, study. And then 2006 came along…

Things got tough for me in 2006 and my second so-called “depressive” episode happened. I lost the joy in everything, study was a hassle, I became morbidly preoccupied with my own mortality, a great solitude and loneliness came over me, and I wanted nothing because simply wanting anything required effort. The social withdrawal and pathological shyness again set inside me. Then I got into a situation where a false accusation was made against me. I was feeling pressure from my religious peers and my internalized God concept. In essence, I felt deficient. I felt lacking. And I felt dead inside – and then the feeling to externalize what I felt inside came over me. I lacked the motivation, the energy and willpower to do even that. Fearing my own internal monsters, I chose instead to go again in search of Vanessa.

Once I left everything, I felt both a great freedom and a complete hatred and fear of that freedom. There were no friends, no company on my journey, I had some advice but which felt more like orders. I had no allies – and I didn’t want anything or anyone even if there had been such people there. At first the numbness overwhelmed me and I was as a ghost walking around (which I recognized because this was not the first time in my life I have had these “episodes”). Gradually, over the next few weeks, reality and the mundane started to creep in. I needed to eat, pay bills, move, reply to the questions that were being asked of me. I started then to formulate my own questions. Who is Vanessa? And yet, not so much who is she but who does she want to be? Why does she want to be that? Does she really want to be that? What does being that entail, the practicality of it? And what of everything else? What is important? Who is important? Who, if anyone, is my friend? And what do I do with these things I love but won’t make me any income? And what should I do about these things that keep pestering me, these things others call conscience? You’ll often hear me diss and complain about the ‘white man’s stupid concept of “finding themselves”’, but you could say that that is what I set out to do.

Specifically I had some questions to answer and that was my quest in this time without commitment to study to answer. Formulating the questions was the easy part. Even finding the answers while on the quest wasn’t that hard. Finding what you’re looking for is easier when you know what it is you’re looking for. The hardest part was making the decision to take a break from my study, my big commitment at that time, to go on my quest. I risked a lot. I risked losing my friends, my family’s belief in me, jeopardising potentially years and years of prior education (and money), and losing my credibility. But I made the choice and I then had to go exploring my questions, myself, trying out different scenarios and risk finding out that my whole life had been a sham. But sometimes not knowing is as deleterious as finding out an unpleasant truth.

The second part of my task, after walking away from it all, was easy: I had the question that needed to be answered. Did I really want to do medicine as a career or was it a childhood dream of mine that I expressed and no-one ever had the courage to shut me down about it despite all the odds being stacked against me? I was a poor kid in a third world country where tertiary education costs more than entire families need to survive. It was a nice fantasy that they let me believe for a long time – until fate and relocation made my dream a possibility. But I was always a stubborn person, did I want to go into medicine purely as a whim? To prove people wrong and that I could do it? They were questions, and I answered them fairly quickly, actually. I think that giving yourself the space to not feel judged is very empowering. People may still be judging you, and I remember a lot of “friends” and even family members discounting me as a drop-out, as someone with no stamina, as a loser. But me, I gave myself the space I needed, I didn’t need anyone’s permission to explore my own life and motivations.

Like I said, the process of answering my questions took a remarkably quick time after I let go of the restraints I allowed to be placed on me by society, by other people’s expectations, by my own pride, and by my pessimism and distorted view of ‘reality’. And in the process, I learnt not only who I in fact was, but also to no longer despise myself for not being what was ‘expected’ of me. The answer to my questions were:  yes, medicine is what I, Vanessa, want to work in; and this will be a job like any other. I came to this conclusion by considering the things I enjoy (writing, visual arts, and film and theatre) and the things that I could bear to do for income. I could not bear to do anything other than medicine as income, and I’d perhaps do it even without income if something else where somehow feeding me. At the same time I was able to explore many aspects of the medical profession, and I had no grand illusions about it like a lot of people do, illusions of ‘saving’ people or of ‘making a difference’. I came to understand a lot of the industrial and organisational psychology of the business. And I became comfortable with what I learnt.

The rest came easy. The friends elected themselves by being the only ones standing when everyone else had gone. I bit the bullet and made a religious commitment. I got a “money” job because I was already planning for my future and my dream to see the wild condors in the Andes in South America. I in fact spent the remaining months of that year killing time by working and entertaining myself until my return to uni and getting on with my task of achieving the next task on the journey. So guess what I do now for work? Medicine. And guess what I do for passion? Write. And I can now unashamedly say that my name is Vanessa and I know exactly who Vanessa is.

Condor! Colca Canyon - Arequipa, Peru

On guilt and religion

There was something I postulated some years ago now when I noticed the number of people in my Christian congregation who were “depressed”: that there may be a positive correlation between Christian faith and depression. I know, correlation doesn’t imply cause and effect, but let’s explore it.

Mea culpa. It means, literally, “my fault” in Latin. It is one of the commonly recited orations in Catholic worship – but not only that, the concept of “confessing blame” is key to most Christian denominations. Briefly, the concept originates from the belief that Adam and Eve sinned against God and therefore inherited sin to all their progeny. Therefore we are all guilty of sin – and hence the need for a redeemer: the Messiah. Gradually the belief came to be that the greater the guilt expressed by a person, the greater his faith was seen to be. The expression of guilt came to take on the form of martyrising practices like self-flagellation, long pilgrimages, and the walking on bare knees to certain sacred places. In modern times these practices are no longer popular amongst Christians, but their roots may remain in the mental processing modes used by the faithful.

One of the diagnostic criteria in the DSM-IV, a medical text used for the diagnosis of mental illness, for depression includes “feelings of worthlessness or excessive or inappropriate guilt”. Now if you consider what we said previously about how in Christian belief the greater the guilt, the greater the perceived faith, it isn’t hard to see how this characteristic of “faith” can easily become one of a mood disorder. We no longer self-flagellate, but we often torment ourselves with guilt, self-loathing, worthlessness, and eventually hopelessness (which can be thought of as a loss of faith in our own ability for self-efficacy). With the growing guilt and hopelessness, the road can be paved for an external source of hope: God, Jesus, or whatever deity you may choose to worship.

Am I trying to say that religion causes depression? No; in the same way I am not saying that religion can “cure” depression. What I am trying to point out here is the perhaps propensity of certain personality types (e.g. the self-sacrificial, perhaps charitable, nice folk that faithfully report to church regularly) to become both the ideal Christian and, unfortunately, perhaps also the person who struggles with depression in his everyday life. And I think this is how the higher rates of depression in faithful religious-abiding persons comes about. Like I said, maybe not cause and effect, but perhaps correlation by a common personality type.

It is interesting to note, however, that when Christ was asked what was the greatest commandment of God’s law, he mentioned nothing of guilt or sacrifice or of rendering homage. He summarised it all in two simple concepts: “Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like unto it, Thou shalt love thy neighbour as thyself. On these two commandments hang all the law and the prophets” (Matthew 22:37-40). Really, that was all the masses of laws Moses and others wrote down were about! So what makes a “good” Christian? Certainly not how much mental or physical anguish a person endures by his own means. Isn’t the Christian belief also that God created the heavens and the Earth with all their magnificent glory and beauty? Surely it can’t be a sin to worship God with gratitude and appreciation of all the blessings of creation.