Monday, December 13, 2010

Holiday Greetings ...

I am, like many of the rest of you, up to my ears in holiday preparations. The tree is up, likewise the Dickens Christmas Village. My favourite carols fill the air. I have thought about doing some baking, but that's about as far as that's gone!

Next week, I will make my annual trip to Nanaimo, on Vancouver Island, with my car filled with gifts for family and friends and my heart filled with the anticipation of happy hours spent in the warm love and laughter of dear ones. I will be away until December 28th so won't be posting again until the New Year.

In the meantime, I wish you the blessings of peace, joy, healing and comfort this holiday season and leave you with these words from Grace Cathedral, San Francisco, found in this year's Callanish Society Christmas card:

We give thanks for places of simplicity and peace.

May we find such places in ourselves.

We give thanks for places of freedom and beauty.

May we find such places in ourselves.

We give thanks for places of refuge and love.

May we find such places in ourselves.

May we begin to mend the outer world

According to the truth of our inner life.

Sunday, December 5, 2010

Self Care Books for the Holidays ...

Yesterday morning, I spent a few hours looking through books at a friend's bookshop in Vancouver. I was looking for Christmas presents and for some new books that I could recommend to you in today's blog post - and I have to say, I struck it rich. Here are three of the books that topped my list:

1. A Life of Being, Having, and Doing Enough by Wayne Muller (2010)

In this sequel to Sabbath: Finding Rest, Renewal & Delight in Our Daily Lives, Wayne Muller, founder of Bread for the Journey, a nonprofit organization that supports community organizing, explores the notion of sufficiency - not "the cramping fear of scarcity, the bloated saturation of over-abundance, but the gentle, effortless release of easy sufficiency".

He addresses the difficulty we have taking a Sabbath, slowing down, or stopping for replenishment and renewal - the difficulty of allowing our work to feel sufficient for the day. He challenges us to listen to our inner thermostats for signs that we have done enough, signs that it is time to take a break or stop altogether.

Wayne, a heart attack survivor who must now live within the limits of his energy, identifies obstacles to living a life of enough - our to-do lists, the fantasy of getting caught up, our inability to slow down or to handle silence and stillness, our harsh self-judgement and our addiction to endless self-improvement and progress.

He also describes the blessings on the road to a life of enough - the ability to see the value in small things, to have mercy upon ourselves, to see the growth that can emerge from loss, to enjoy the benefits of good company, to recognize the sufficiency of presence, and to see the value of bearing witness.

2. In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter Levine (2010)

In this book, American medical biophysicist and psychologist, Peter Levine, shares the essence and underpinnings of his life's work - Somatic Experiencing - a type of body psychotherapy used for healing psychological trauma.

In a style that reads like a mystery novel, Peter clearly and descriptively explains that trauma resides in the "unspoken voices" of our bodies. Using animal ethology (the study of animals in their natural environments), brain research, native healing practices and his lengthy clinical experience, he shows how traumatic experiences result in psychological injuries that can be transformed by paying attention to the natural healing processes deep within our bodies.

In chapters entitled, The Power of an Unspoken Voice, The Changing Face of Trauma, Immobilized by Fear: Lessons Learned from Animals, From Paralysis to Transformation, A Map for Therapy, The Body as Storyteller, and Body, Emotion & Spirituality: Restoring Goodness, Peter leads us through a body-based healing process that acknowledges our frozen trauma responses and safely paces our developing awareness and mastery of our physical sensations and feelings. He teaches us to self regulate and to allow for the completion of survival responses that were inadvertently cut short at the time of the trauma.

The integration of body psychotherapy and "talk therapy" is the new frontier in trauma work and, in my opinion, there couldn't be a better introduction to it than this visionary book.

3. Haiku Mind: 108 Poems to Create Awareness & Open Your Heart by Patricia Donegan (2008)

Patricia Donegan, poet, translator, and promoter of haiku as an awareness practice, has written this lovely commentary on the haiku of many poets, including herself.

She begins the introduction with a haiku by Shiki Masaoka, -

Cutting a pear
sweet drops drip
from the knife

and says-

I wanted to write this book to share the idea of "haiku mind" -
a simple yet profound way of seeing our everyday world and living our lives
with the awareness of the moment expressed in haiku -
and to therefore hopefully inspire others to live with more
clarity, compassion and peace.

A fine haiku presents a crystalline moment of heightened awareness
in simple imagery ... However, this moment is more than
a reflection of our day-to-day life - it is a deep reminder
for us to pause and to be present to the details of the everyday.

Patricia goes on to share 108 haiku, each with a brief commentary and a short biographical note about the poet who had written it. A lovely read with which to begin or end the day or with which to enjoy a restful cup of tea.

I hope you will enjoy some of these books over the holidays and that you will feel free to add to the list any others you think your fellow caregivers/carepartners might like to read.

Tuesday, November 23, 2010

Holiday Help for Family Caregivers ...

Family caregivers spend endless time and energy caring for loved ones who are ill, disabled or frail and are often unable to participate in the usual traditions and activities of the season. Thoughtful assistance and gifts from those who love them can make all the difference to the quality of their holidays.

Here are some ways you can help the family caregivers in your life:

1. Ask what's needed or wanted before you shop, bake or make plans. Every caregiving situation is different and the needs of each caregiver are different as well. I remember receiving several lovely packets of bath salts and oils one Christmas while caring for my husband. They would have been wonderful to use had we had a bathtub!

2. Consider that while the gift of an afternoon's concert, play or special event might be much appreciated, it needs to come with the second gift of someone qualified to stay with the care recipient so the ticket can be used.

3. Gifts of food can bring real relief from the monotony and fatigue of cooking, but remember to ask, first, regarding personal preferences, allergies and dietary restrictions. We frequently passed on to others casseroles whose salt content was too high for my husband to eat. (Including a copy of the recipe can help to reduce anxiety in this regard.)

4. Try to avoid gifts that need assembling, that are outside the caregiver's previous experience or that are very complicated (technological devices with multiple functions) unless the caregiver has asked for it, specifically. (Impaired cognitive function is a hallmark of caregiver stress and most caregivers find it hard enough to remember where they put their keys , let alone how a new device works.)

5. Avoid giving anything that will need special care - this includes anything from a delicate plant to "a nice pet to keep you company". Now is not the time to inadvertently add to the caregiver's burden.

6. Consider safety in all gift giving. eg No glass figurines, knife sets, or barbecue lighters for caregivers of children with aggressive or impulsive behavioural disorders, unless there is safe storage space that is out of sight.

7. Consult with the caregiver before buying gifts of perfume or other scented materials that might aggravate allergies or respiratory conditions. (Their own or that of the care recipient.)

8. Consider gifts of your time and presence - "gift certificates" for mowing the lawn or shovelling the walks on a regular basis or for sitting with the care recipient so the caregiver can get out for errands or respite, or for short biweekly or monthly visits for a chat and support. (But be sure that you can follow through with whatever you promise.)

9. Offer to buy and put up the Christmas tree or other decorations - but be sensitive to the loss involved in changing a holiday tradition. Check at each stage in the process to see if that step is something that the caregiver would rather do alone. Perhaps you could buy and set up the tree and lights and then leave the decorating to them or perhaps they will want you to do the whole job. Just keep asking.

10. Offer transportation to shopping malls or to doctors appointments. Return library books or DVD's.

11. Offer to do the caregiver's holiday shopping or wrapping or to help them to navigate shopping on the internet.

12. Talk about plans for holiday dinners well in advance. But be prepared to change plans at the last moment if the care recipient is ill or the caregiver is too tired. Ask what will make life easiest for the caregiver - to have you make and deliver a meal on plates then leave, to eat altogether at your house or theirs, to have a pot luck or share the cooking, to go out for a meal?

13. If you're "going home for Christmas", ask if it would be easier if you stayed in a nearby hotel.

These are just a few possibilities. Please add your own ideas to the list. The important thing is to be thoughtful, empathic and accepting in the face of the caregiver's stress, indecisiveness and desire to hold on to the things that have meant the most to them.

Thursday, November 11, 2010

Remembering ...

Every year on November 11th, sometimes in clear brilliant sunshine, sometimes in blustering winds and sheets of rain, we gather around cenotaphs across the country to honour and show our gratitude to those who have given their lives or their health for our safety. Those who have come home injured, whether with physical wounds or operational stress injuries, have come back with their lives changed forever and their altered lives alter the lives of all who love them, particularly their family caregivers/ carepartners.

These family caregivers are as affected by their loved ones' injuries as their loved ones are themselves. No area of their lives is untouched. And yet, all too frequently, family caregivers are the unsung heros of our wars and peacekeeping missions. They are the glue holding families together during long or repeated deployments and once their partners are injured, they take on a myriad of additional responsibilities as nurses, rehab specialists, psychotherapists, cheerleaders and advocates. It is through their support and daily efforts that the members of our military have as much as they do, in order to recover.

And yet, this support for recovery comes at a cost. Energy and resources that would otherwise have been spent nurturing the growth and development of family life must be diverted to recovery from injuries and, worse, to fighting a bureaucracy that seems to have little access to common sense, empathy or compassion. Already overwhelmed by the enormity of the task of recovery and adjustment, veterans and their family carepartners can face an unwieldy, inefficient and seemingly uncaring response to even their simplest requests.

This week, however, a wide ranging group of deeply caring Canadians, led by the vision and efforts of people like Allan De Genova, took a giant step toward supporting our wounded veterans and other first responders and their families with the opening of Honour House in New Westminster, BC.

Set on a quiet street not far from the New Westminster Armoury and the beautiful Japanese Gardens where I played as a child, Honour House is a fully accessible residence that will temporarily house up to ten families who must relocate to Greater Vancouver for a loved one's treatment and rehabilitation and who, in the past, would have endured long separations at a time when they needed each other most.

The ability to stay together as a family unit during long months of recovery will make all the difference to the quality of that recovery for the whole family. Hopefully Honour House is just the first of at least ten provincial houses that will support these families who have given so much for us. And, hopefully, the federal government will come to understand the importance of such support and add federal funding to the mix for the houses yet to come.

Monday, November 1, 2010

Cumulative Grief in Healthcare Professionals ...

Earlier in the fall, I mentioned that I believe there is a missing, or at least underemphasized, component in our consideration of compassion fatigue in health care professionals. That component is cumulative grief.

Most of us are familiar with the Baranowsky-Gentry model of compassion fatigue which states that primary traumatic stress (the trauma that happens to us directly or that we witness directly), secondary traumatic stress (the trauma we experience indirectly through knowing about trauma in others' lives) and burnout (the chronic stress of perceived workplace demands exceeding perceived resources) converge in the life of the helper to cause compassion fatigue, a diminished capacity for or interest in being empathic with another's suffering.

As I have worked with family caregivers, I have modified this model a little to say that primary traumatic stress and secondary traumatic stress, in the presence of burnout and Chronic Sorrow, can lead to compassion fatigue. I have found this change to be helpful in emphasizing that CF is primarily a trauma issue that occurs in conjunction with burnout - not a form of burnout, itself, - and that the grief of Chronic Sorrow, extending from a loved one's diagnosis until his or her death, may also contribute to family caregivers' vulnerability to CF.

Once I had adjusted my CF thinking to incorporate the Chronic Sorrow of family caregivers, I began to wonder about the cumulative grief of healthcare professionals.

Grief is our normal, hardwired, healing response to loss and it will generally heal itself if we stay out of the way and support rather than blocking the natural process. But what if we work in an environment where loss is the norm? What if we form caring attachments to patients and families over and over again only to have the patients die and the families to move on with their lives? What if we work in environments that do not make time and space available to process our own grief or, worse, those that ridicule and shame such "weakness"?

There is a significant and growing literature base, still at the descriptive stage for the most part, focused on cumulative grief, which is defined as:

... our emotional response to the occurrence of multiple deaths,
either at the same time or in serial fashion,
without sufficient time or opportunity to
adequately grieve for each person who has died.

P. Marino (1998) Paraphrased

Phenomenological studies on cumulative grief have emerged from the fields of palliative care, oncology, critical care, paediatrics, gerontology and advanced nursing practice, particularly since the mid-1990's. There are also several professional magazine articles offering advice on how to cope with this accumulated grief, testifying to the importance of the topic at the grass roots level of practice. Last week's episode of CBC's White Coat, Black Art called, "When Your Life is Circling the Drain", reflects the impact of multiple deaths on young medical residents.

Not all work-related losses are considered traumatic, especially when healthcare practitioners have been able to provide "a good death" for both the patient and the family. Thus cumulative grief doesn't fit easily into our currently-held understanding of CF. However, these losses are real and can have a significant impact upon us, especially if left unattended. Do they actually contribute to increased vulnerability to CF? We don't know that yet but it is a rich area for further research.

In the meantime, I will continue to address cumulative grief within the context of CF in my healthcare workshops as it almost invariably and spontaneously comes to the fore.

Photo by BigStock Photos

Wednesday, October 20, 2010

Companioning through Grief...

Although it is a bright and vibrant fall morning here in Vancouver, my thoughts are focused on grief. A dear friend's mother died of mouth cancer two nights ago, I have been asked to speak to a group of family caregivers who have lost a loved one to ALS and I am rereading the transcript of a seminal keynote address given by Dr Alan D Wolfelt to the Association of Death Education and Counselling conference in Chicago in 1997 entitled, Companioning vs Treating: Beyond the Medical Model of Bereavement Caregiving.

These three occurrences have combined to return my thoughts to the early days of my own bereavement following the death of my husband and, 3 months later and quite unexpectedly, that of my mother.

During those days I was completely depleted, shell-shocked and bereft. Friends and family surrounded me with love and support but, as is often the case in our North American culture, that support gradually dwindled as time went on. Some, who didn't understand the the notion that grief takes as long as it takes, became impatient and frustrated with their inability to "fix" me. Others, who had walked the path of grief before me, waited patiently for the the cloud of sorrow to lift and stood again and again with hearts and arms wide open as, after periods of "improvement", that cloud of grief descended once more in the face of anniversaries, holidays or family celebrations.

Five things helped me through those months and years of sorrow:

1. The incidental comment of an acquaintance whose husband had died years before mine - "It will take 5 years before you know who you are without him". With this comment she gave me permission to take as long as I needed to grieve. The number of years wasn't important. It was the implicit expectation that my grief would take as long as it took. (For some, a long goodbye has already been said and soon after the death there is a sense of relief and an early readiness to engage with life again. For others, the road is longer.)

2. Moorings, the beautiful writings of Rabbi Vicki Hollander. Vicki had been my grief counsellor for a brief period during my husband's illness and, when she moved away to Arkansas and then to Texas, she left me with these poetic and practical reflections on what I might expect at different times during the first year and a half of my bereavement.

3. The Two of Us: My Life with John Thaw by British actress, Sheila Hancock. This autobiography / biography has been, rather surprisingly, a great source of comfort over the years. Interspersed between stories of her life with actor, John Thaw, (Morse, Kavanaugh QC, Mister Tom) are italicized selections from her journal telling the story of his cancer diagnosis, death and her early bereavement. Reading these segments was the most empathic experience of my bereavement and I will be forever grateful for the intuitive love and generosity of my husband's cousins who left a copy on the bookshelf in my sitting room during a visit to England in the Spring following Derrick's death.

4. The support of my spiritual director / grief counsellor whom I saw on a weekly then bi-weekly basis.

5. The support of family and friends who stayed in for the long haul, waiting until the sun shone again in my life.

What was the experience that linked these five supports? The experience of companioning. As Alan Wolfelt said in his keynote, companioning is different from "treating" or "fixing":

More specifically, for me ...

* Companioning is about honouring the spirit; it is not about focusing on the intellect.

* Companioning is about curiosity; it is not about expertise.

* Companioning is about learning from others; it is not about teaching them.

* Companioning is about walking alongside; it is not about leading.

* Companioning is about being still; it is not about frantic movement forward.

* Companioning is about discovering the gifts of sacred silence; it is not about filling every painful moment with words.

* Companioning is about listening with the heart; it is not about analyzing with the head.

* Companioning is about bearing witness to the struggles of others; it is not about directing those struggles.

* Companioning is about being present to another person's pain; it is not about taking away the pain.

* Companioning is about respecting disorder and confusion; it is not about imposing order and logic.

* Companioning is about going to the wilderness of the soul with another human being; it is not about thinking you are responsible for finding the way out.

If you would like to learn more about companioning and other aspects of grief recovery you can read more at Alan Wolfelt's Griefwords.

Tuesday, September 28, 2010

Thanksgiving in the East ...

If the only prayer you ever say in your entire life
is thank you, it will be enough.
Meister Eckhart

I'm off to Toronto in the early hours of Thursday morning to speak at the ATSS conference and then I will be driving down to Kingston to spend Thanksgiving with dear friends there.

I've been thinking about Thanksgiving and "gratitude" over the past week and was surprised to find an echo of my thoughts in an article in the Winter 2009 newsletter of the Callanish Society.

(Callanish is a wonderful nonprofit organization, worthy of your support, that provides retreats for people living with cancer and their families. A number of years ago my best friend, Linda Vick, attended one of their retreats before dying of lung cancer. It changed her life and touched many of us through her. I still have the journal she kept during her week's retreat - a treasured gift - and I read it from time to time when I need a reminder of what matters most in life.)

Janie Brown, Executive Director of Callinish, wrote these words in the Winter newsletter -

Many of us need to work at feeling grateful when life turns around on us.
A good friend of mine, Roger Hyodo, writes about thankfulness. He speaks about
two kinds of gratitude. The first is one that we cultivate based on our preferences,
beliefs, and values. We like something, we feel grateful. We don't like something,
we feel ungrateful. Our state of internal thankfulness is dependent on the ups and
downs of our lives. There are some people who tell us that we should see
everything as a gift, and that every experience that arrives is meant to be.
This is all very well, but what we cannot do is will ourselves to be grateful. It doesn't
work. All we do then is bypass our sadness, anger and regret, and send those feelings underground. At Callanish we offer a space for people with cancer to have their feelings, to honour the dark emotions by giving voice to them. In time, and it takes time,
I hear people speak not of cancer as a gift, but of life as a precious commodity.
Even in the midst of fiercely rejecting cancer, people can become clear that
there are things worthy of thanks.

The second form of gratitude Rodger speaks of is one that we may sense as a
"field" of thankfulness. I have experienced this many times in our circles at Callanish,
as well as in many other moments of my life. When we deliberately create certain conditions in our living, we become aware of this underling ever-present
quality of thankfulness.
Some of the conditions at Callanish are beauty, silence, real conversation, music,
art and spontaniety. We find ourselves risking expression to speak what is
true for us. In this kind of space, the heart seems to unabashedly open in response to
another's honesty, and we feel thankful. It feels like this thankfulness moves
effortlessly among us.

Perhaps, then, in these times of great uncertainty in our lives, it is up to all of us
to create these conditions for ourselves and each other ... whereby we can touch into
a genuine feeling of gratitude for the lives we are living.
When I hear someone express thanks amidst a life of great struggle, it humbles me to
look at my own life through a different lens. With that view, how could I not say,
"Thank you".

So, for Linda and Derrick and Barry and Mom and Dad and Christopher who, through times of great struggle, taught me about thankfulness, beauty, silence, real conversation, music, art, spontaneity, and mostly, love - I, too, say, "Thank you".

Tuesday, September 21, 2010

Book Review: After the Tears ...

Earlier this month, Health Communications published a revised and expanded edition of Jane Middelton-Moz and Lorie Dwinell's 1986 popular classic, After the Tears: Helping Adult Children of Alcoholics Heal Their Childhood Trauma.

This new edition has been almost entirely rewritten to reflect new information regarding trauma, posttraumatic stress disorder (PTSD), delayed grief and newly-discovered brain physiology. Entirely new chapters include those on resilience in children of alcoholics, ACoA's as parents, ACoA's in the workplace, acceptance and forgiveness, and spirituality for ACoA's.

Not surprisingly, the first of the new chapters to catch my eye was one entitled, A Pain Too Deep: ACoA's Taking Care of Elderly Parents. Here, Jane Middelton-Moz describes an issue common to many adult children of trauma - that of caring for elderly parents who have not cared well for you. While for some, therapy and personal growth in the intervening years have meant that parental caregiving is an opportunity to give back, lovingly, to parents who did the best they could, for many, "... the task can be especially daunting ... (when) navigating a minefield of emotional hurts and abuse from the past". Jane goes on to say that -

Adult children frequently end up caring for elderly parents who were not there for them in their growing up years, and who were sometimes physically and/or sexually abusive to them as well. Many alcoholic or codependent parents had lives that resulted in chronic PTSD, and they often were not appropriately cared for themselves as children. As a result, many were suffering from their own developmental losses while raising their children. They may have been neglectful, clinging, dependent, abusive, controlling, ill-tempered, or demanding parents who not only were ineffective as parents but demanded to be parented as well. As a result, many Adult Children also suffered from PTSD most of their lives. Within this framework, these Adult Children are then commandeered one more time to take over the care of their parents physically and emotionally, and for some, to rescue them financially as well; all of this while being their parent's primary caregiver.
Many of the Adult Children who are responsible for elderly parents are themselves in their sixties or seventies and are taking care of parents in their eighties and nineties. For many, this is the time they believed they would finally be able to relax. They have achieved some level of financial security and career satisfaction and often have new and improved relationships with siblings and parents. This tests their limits and can cause some ACoA's to revert to earlier roles and painful interactions with both siblings and parents. While some elderly parents who need care may have gone through recovery, others may be as emotionally difficult as they ever were - or may even be worse. (p 218-219)

Why does all this matter? Because in many jurisdictions, including British Columbia, a Guardianship Act or similar legislation legally binds adult children to the care of their dependent parents. Understandably, when unresolved trauma is in the mix, such situations can hold the potential for elder neglect or abuse and they call for case-by-case assessment and adequate support from knowledgable case managers before a parent is placed in the care of an "unrecovered" adult child.

Another seldom-acknowledged observation made in this chapter is that adult children of alcoholics can find themselves caring, not only for their own children and for their parents, but for adult siblings who have "fallen by the wayside" as the result of their own childhood wounds. When this situation is combined with a lack of psychological separation from family members and an enhanced empathy for others' suffering, (both products of traumatic families), it can lead to a caregiver burden that is on a fast track to burnout and compassion fatigue.

Jane and Lorie offer a number of self-care recommendations for ACoA caregivers including:

  • 1. Developing the ability to define yourself and to set caregiving limits. (This is often best done with the support of a therapist who has expertise in treating both caregiving and childhood trauma issues.
  • 2. Not expecting siblings to behave differently from their usual roles and patterns under the stress of a parent's illness or infirmity. (Families almost always revert to their original patterns in the face of serious stress.)
  • 3. Remembering that you do have a choice regarding how much caregiving you are willing to undertake. (You may not be able to change your family's response, but you can change your own behaviour.)
  • 4. Planning ahead and formally scheduling self care time. Making it a priority.
  • 5. Giving yourself the gift of support. (Many adult children develop a protective counter-dependence that can cause them to feel shame regarding their natural need for support.) Consider seeking a good therapist or 12 Step support group. If you can't leave home, join an on-line support group run by a reputable organization.

This practical and readable volume has been a gift to ACoA's for almost 25 years and the new, expanded version will enlighten and promote the healing of a whole new generation of adult children.

Monday, September 13, 2010

The "Dr Peter" Tapes ...

About 20 years ago, I went to church in Burnaby BC one Sunday morning to find that the homily was to be given by a young man named Peter Jepson-Young. My minister had heard the first of the "Dr Peter" tapes on CBC Radio and had immediately called to ask him if he would consider coming to talk to the congregation. That Dr Peter answered, "Yes", was a testament to his grace and courage because the Christian church at that time was frequently less than kind and inclusive in its response to people with HIV/AIDS.

I remember a nervous but thoughtful, articulate, deeply honest and very funny man who, despite failed eyesight, stood alone on the chancel steps to give us a real picture of life with HIV/AIDS. He taught and reassured and made human the face of a little known or understood disease. We laughed and cried as he spoke and many people stayed a long time after the service to speak with him and his family.

That one 20-minute talk changed the hearts and minds and attitudes of people who had previously been frightened to even hug a person who was HIV positive. In the years to come, the minister became a chaplain to our church's support organization for gay, lesbian and transgendered people and the congregation continued to support the Dr Peter Foundation and the Dr Peter Center. We all grieved on the day of Peter's death in 1992.

This September, Vancouver has declared a Dr Peter Week in appreciation of Dr Peter Jepson-Young's contribution to the quality of life of those affected by HIV/AIDS. CBC Radio is marking the 20 year anniversary of the tapes by featuring them on their broadcast and website and there will be fundraising events for the Foundation all around Vancouver. Please take a moment to visit the CBC site and take in the details.

During one of his most poignant broadcasts, Peter shared his Affirmation with his viewers. Let me share it with you today:

I accept and absorb all the strength of the earth
to keep my body hard and strong;

I accept and absorb all the energy of the sun
to keep my mind sharp and bright;

I accept and absorb all the life force of the ocean
to cleanse my body and bring me life;

I accept and absorb all the power of the wind
to cleanse my spirit and bring me life;

I accept and absorb all the mystery of the heavens,
for I am a part of the vast unknown.

I believe God to be all these elements,
and the force that unites them;

And from these elements I have come
and to these elements I shall return;

But the energy that is me will not be lost.

Dr Peter Jepson-Young, MD
Dr Peter AIDS Foundation

Thursday, September 9, 2010

Safety in Our Hands: Helping Our Helpers Stay Healthy ...

Of great interest to anyone in the trauma field this Fall will be the 2010 Association of Traumatic Stress Specialists Conference to be held in Toronto, Sept 30 - Oct 2.

With the theme and focus of keeping helpers well, the conference offers a wide selection of more than 30 workshops including:

Keynotes -

1. Dr Angie Panos - Safety in Our Hands: Helping Our Helpers Stay Healthy

2. Lt Col Stephane Grenier - ( Canadian Operational Stress Injury Special Advisor) - Peer Based Mental Health Services

Workshops -

1. Question & Answer Session: Preventing & Healing Compassion Fatigue
Dr Angie Panos

2. Creative Tools for Transforming Compassion Fatigue and Vicarious Trauma
Francoise Mathieu

3. Caring on Two Fronts: When Helping Professionals Become Family Caregivers
(Chronic Sorrow in the Context of Compassion Fatigue)
Jan Spilman

4. Meditation, Mindfulness, and Right-Brain Healing
Dawn Bret

5. HUGS: Helping Children Understand Grief & Trauma in Six Week Sessions
Christina Derneder Landen

6. CISM in the Correctional Service of Canada
Pamela Scott & Dorothy Reid

7. Voices of Experience
Pricilla de Villiers, Kent Laidlaw, and Edward Leonard

8. PTSD & Addiction Treatment for Occupational Hazard: Strategies for Symptom Reduction
Anne Pepper

... and much more.

I'm particularly pleased to have been chosen to speak at this conference because, for the first time, I will be combining material from the Compassion Fatigue and Chronic Sorrow fields as a means of expanding our understanding of the stress of "caring on two fronts".

Please join us! To register, click here.

Photo by Bigstock Photos

Monday, August 30, 2010

Fall Workshops ...

After a beautiful summer there is already a hint of fall in the air. The days are closing in, the garden is yielding it's bounty, and although the days are bright and sunny, my furnace has cut in for the first time since spring. I love this time of year! It has an energy and excitement all it's own.

My speaking engagements have begun early this year with an August keynote for the Canadian Society of Transplantation Conference at the Vancouver Convention Center. I was privileged to spend time with a fine group of helping professionals working on both the donor and recipient sides of the transplant equation. Their comments and questions in relation to Compassion Fatigue dovetailed with the thinking and reading I've been doing over the summer and have confirmed some of my thoughts regarding an under-acknowledged piece in our conceptualization of Compassion Fatigue. More about this later in the fall.

This October and November will see me sponsoring two of my own workshops for helping professionals here in Vancouver. The Caring on Empty and Compassion Fatigue, Going Deeper: The Enneagram workshops were so well received last year that I will be co-sponsoring them with St Mark's Anglican Church in Kitsilano and offering them to a broader, more heterogenous group of professionals than one might find in a specific organization. There is usually great richness in such groups with opportunities to think outside the box and to benefit from the wisdom of others outside one's own particular field.

1. Caring on Empty: Creative Tools for Transforming Compassion Fatigue

Friday October 22 9:00 - 3:45 (Registration at 8:30)
St Mark's Church, Kitsilano
1805 Larch Street, Vancouver, BC
Registration fee: $184.80 + HST = $210

This is a workshop designed for all helping professionals who work with the suffering or traumatized, from veterinarians to clergy, from nurses to teachers , from physicians to lawyers and judges, from social workers to physiotherapists to psychotherapists.

You will benefit by:

1. Learning the difference between compassion fatigue, (the secondary trauma we can experience through working with those who have been traumatized), and burnout or vicarious trauma.

2. Gaining an understanding of how CF develops.

3. Recognizing the general signs of CF and your own personal early warning signs.

4. Identifying your current level of CF.

5. Exploring tools for CF transformation and resilience.

6. Beginning to develop a personal recovery and resilience plan.

2. Compassion Fatigue, Going Deeper: The Enneagram (** Postponed until 2011)

Friday evening November 19 7-9:00 pm - and -
Saturday November 20 9:00 - 3:45 pm
St Mark's Church, Kitsilano
1805 Larch Street, Vancouver, BC
Registration fee: $220 + HST = $250

One of the most common signs of Compassion Fatigue is emotional reactivity and the Enneagram can help you to recognize the source of that reactivity and to take steps to reduce it.

The Enneagram (pronounced ANY-a-gram) is an enlightening and powerfully accurate system of 9 personality types based on a combination of ancient wisdom tradition and modern psychology. It differs from other personality typing systems like the Myers-Briggs in that it focuses on the motivation behind our behaviour rather than on the behaviour itself.

Discovering and working with your Enneagram personality type can help you to:

1. Make positive changes in your life, particularly in your relationship with yourself and with others.

2. Clearly recognize the issues that can "push your buttons" and reduce your reactivity.

3. Understand more about your behaviour under stress and when relaxed.

4. Integrate the personal and spiritual aspects of your life, regardless of your spiritual path.

** Registration includes a copy of Stanford University professor of psychiatry, Dr David Daniels' book, The Essential Enneagram.

For a registration form or for more information, please email me at or call me at (604) 297 0609.

With every good wish for a healthy and happy fall,


Sunday, August 8, 2010

12 Step Recovery for Helpers...

Caring for others, whether as helping professionals, volunteers or family caregivers, can be a great source of fulfillment and satisfaction. It can also be a source of tremendous emotional strain. One of the ways that helpers are dealing with this strain is through attending 12 Step meetings and applying the program's principles in their everyday lives.

The 12 Step program was started by two alcoholics in the 1930's as a means of staying sober. They then formed Alcoholics Anonymous (AA) to share the program with others. Since that time the basic principles of the program - the 12 Steps - have been adopted by millions of others with chronic problems as varied as chronic over eating; other compulsive behaviours such as gambling, over exercising, over spending, or over working; and codependence. Many others, drawn by the inclusive, non-religious spirituality of the program, have chosen the 12 Steps as a practical pathway to peace and serenity in a chaotic world.

While not for everyone, the program helps many to relinquish control of the unmanageable, out-of-control portions of their lives to a Higher Power, however they understand that Higher Power to be. In doing so, they become more able to move with the flow of life rather than struggling against it and they learn to lean on their Higher Power for strength and support.

As author and family caregiver, Gail Sheehy, writes in Passages in Caregiving:

I confessed to Dr Pat that I had bottomed out. ... She suggested that I try a twelve step program.

Grateful, but skeptical, I walked thirty blocks down the street from Dr Pat's office to a twelve-step meeting in a large church. I expected a huddle of mournful souls reciting grisly accident reports on the train wrecks they had made of their lives. I had heard such accounts, secondhand, when my mother entered Alcoholics Anonymous for her recovery.

One step into the nave changed everything. Greeters lined the walls. They talked about taking positive steps toward living with gratitude and feeling more joyous and free than before they found the program. They clapped for anyone who announced progress.

I was shocked to find my own behaviour described in some of the stories. Like me, the narrators had attacked their problems guided only by a ferocious self-will. When it didn't work, fear overtook. Or resentment, or both. I realized I had become powerless over my fears. In the fever to "save" my husband, I was losing the ability to manage my own life. I needed to find a way to restore my faith.

This was a spiritual program, but no church affiliation was required. We were encouraged to entrust our wills (or egos) to God, who was introduced with the shrewdly tolerant phrase "as we understand him".

The God I hoped to meet was the source of serenity, the missing force in my life. To my delight everybody else at that meeting had the same idea. At the conclusion, we all held hands and recited the universal serenity prayer by Reinhold Niebuhr:

God, grant me the serenity
to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference.

"The wisdom to know the difference" was not just a catchy slogan. It sounded like something God would grant if I met him/her halfway, by accepting the things I could NOT change - my husband's life trajectory and my own limitations. That was the road to serenity. But first, I would have to quit Playing God. I was full of compassion for my husband, yes, but my caregiving was spiked with more than a pinch of egotism.

I had to find the courage to change the things I could - especially myself. In the twelve-step group everyone learned how to open up and shamelessly examine our defects and draw support from our fellowship. The best laughs are at ourselves, and we had many laughs at those meetings. The days went better after gathering in the early morning with my fellow pilgrims.

Others have written about the usefulness of 12 Step programs in helping caregivers to care for themselves while caring for others. If you are interested in learning more you might want to read, Self-Care for Caregivers: A Twelve Step Approach by Pat Samples, Diane Larsen, and Marvin Larsen.

If you decide to try out a 12 Step group, remember that a group is only as healthy as it's individual members. If you're not comfortable in one group, try several others until you find one that fits for you.

Also remember that any idea can be taken to an extreme or become rigid or warped from it's original intent. I have discovered this in relation to Chronic Sorrow in some groups. The notion of "the pity pot" (being stuck in self pity) has been applied to the ongoing grief of family caregivers by those who do not understand the concept of unending loss. As with everything one finds at a 12 Step meeting, it is always okay to, "take what works and leave the rest".

Tuesday, July 20, 2010

Book Review: Passages in Caregiving...

I have just finished reading Gail Sheehy's latest book, Passages in Caregiving, and recommend it to you with an enthusiastic thumbs up. Whether you are a family caregiver or a helping professional wanting to better understand the family caregiving experience, you will find much to enlighten you in these pages.

Using the turning points of the labyrinth, (a medieval symbol of a single pathway, with several switchback turns, leading to the center of a circle which is used by many spiritual traditions as a form of walking meditation or ritual), Ms Sheehy describes eight turnings in the path around the labyrinth of caregiving:

1. Shock and Mobilization

2. The New Normal

3. Boomerang

4. Playing God

5. I Can't Do This Anymore!

6. Coming Back

7. The In-Between Stage

8. The Long Good-bye

Each of these turnings is a passage in the emotional journey through providing care for a loved one - or a not-so-loved-one.

While drawing extensively and beautifully from her own and others' experiences of spousal caregiving, Ms Sheehy also touches on the experiences of those giving care to parents. Unfortunately, little is said about those caring for children with chronic conditions or about children who are caregivers themselves. Another limitation for Canadian readers is the detailed explanation of the American healthcare system. (Though there are certainly sufficient emotional parallels in our responses to the two systems to make these explanations readable.)

The epilogue is an interesting departure from the usual content of caregiving books with its exploration of sustainable aging and who will care for the aging boomers in a world of smaller and more transient families, fewer resources, and longer lived lives in the presence of complex medical conditions. Gail Sheehy's answer to the latter is an emphatic, "Us!". She offers the model of the "village movement" to those disinterested in an old age of dependence and isolation. This movement uses the yearly fees of members, (paid according to income), and their gifts and talents, to provide each other with the kind of support that small villages and neighbourhoods once offered.

I will write more about this idea, and about the labyrinth, in later posts. For now, suffice to say that Passages in Caregiving is worthy of a place on your summer reading list.

Caveat: Gail's descriptions of her emotional experiences during her caregiving journey with her husband are achingly accurate so, if you are feeling vulnerable or fragile, you might want to try reading just the chapters that currently pertain to you, and then leave the rest for later.

Friday, July 9, 2010

Men as Caregivers ...

When we think of family caregiving, we often think of women providing the care but in fact, men make up more than 30% of all family caregivers and, in some care contexts, provide the bulk of the care. (For example, 40-53% of all primary caregivers to people with AIDS in the United States are relatively young males. And often, fathers must take on more caregiving responsibilities as their children with disabilities grow older and are harder to manage physically.) How do these men experience caregiving and what are their support needs?

Although originally thought to be less negatively affected by their caregiving responsibilities than women, more recent studies have shown that men who are caregivers experience similar caregiving "burden" to women, similar levels of depression, and higher levels of hostility and work-family conflict. As well, brothers caring for parents experience as much stress and emotional strain as sisters but seem to have more difficulty combining work and family responsibilities. Men also tend to be castigated in the caregiving literature for being more likely to "abandon" their care recipients through separation or divorce but in many cases are tenaciously loyal and persistent in their care.

Now, while I personally tend to think that the differences in caregivers and caregiving have more to do with individual personality, history and experience than gender differences, there is research to say that some male caregivers may need:

1. More opportunities to share their feelings and experiences with other men. (There is a tendency for men to accumulate more acquaintances than confidants and thus to have less opportunity to share their experiences.)

2. The availability of formal respite care services during extended caregiving as their male support system is less likely to offer informal respite.

3. Skill-based educational opportunities - bathing, cooking, laundry, etc.

4. Normalization of and relief from the stigma (internal or external) of doing "women's work".

5. Support in communicating their own needs and feelings within the caring relationship.

Saturday, July 3, 2010

Fueled for Caregiving?...

Like you, I suspect, I learned about the five (or six?) food groups and healthy eating practices way back in 5th grade Health class but it wasn't until I was literally falling asleep on my feet as a family caregiver that the penny dropped and I truly realized the importance of good nutrition in my life.

My husband had been both cook and baker in our home from the day we were married and while he had tried to make sure that he'd taught me to bake bread and to put together our favourite dinners before he became bedridden, the standing joke in our family still prevailed - "If anything ever happens to Derrick, Jan will die of a Cheerios overdose!". It's not that I didn't value healthy food when someone put it in front of me - in fact, I loved it - but I had no interest in producing it from scratch myself.

Flash forward a year or two, and you would have found me cooking very small and frequent nourishing snacks for my husband. And indeed, when his snacks didn't appeal to me, eating Cheerios, (garnished with various kinds of fruit to make them "healthy"). Up all day and half the night caring for Derrick AND eating poorly quickly caught up with me. I couldn't think clearly, I had no energy, my colour was poor and I dropped two dress sizes. I would sit down on the couch "for a minute" after lunch and wake up an hour later. And, worst of all, I was grumpy and irritable at a time when I truly wanted to enjoy the days we had left. Now, there were a number of factors that went into creating these symptoms, not just the Cheerios, but it was amazing how much things improved with a little nutritional intervention.

That intervention started when my younger sister, a real foodie, introduced me to
Barbara Jo's Books to Cooks, a wonderful bookstore close to Granville Market in Vancouver. Only my sister would have guessed that the way to this non-cook's stomach was through a book - especially one with smooth, shiny pages and beautiful photographs. The first one she picked out for me to peruse was Dana Jacobi's, 12 Best Foods Cookbook, and I was hooked. Just by looking at the cover, I learned that there were 12 superfoods which, if I indulged in them, would not only make me feel better but would protect me from some of the health problems inherent in caregiving. Those 12 super stars were:

1. Blueberries

2. Black beans

3. Sweet potatoes (or yams, as we call them on the west coast)

4. Oatmeal

5. Salmon

6. Spinach

7. Broccoli

8. Tomatoes

9. Chocolate

10. Walnuts

11. Soy

12. Onions

I bought Dana's book and began to enjoy making Sweet Potato & Broccoli Shepherd's Pie, Scalloped Sweet Potato with Apple, Greek White Bean Soup, Spinach Salad with Nectarine, Blueberries, & Lime Balsalmic Vinaigrette and more. And, more importantly, my energy improved, my irritability eased and my brain began to work again. I learned through experience that fueling my body with good food bearing high quality nutrients, bought in-season to keep the cost down, was one of the best ways I could sustain myself for the years of caregiving ahead - and indeed, for my whole life. (Now, if only someone could break my cookbook addiction...!).

Tuesday, June 22, 2010

Summer Reading ...

I don't know about you, but for me, one of the best parts of summer is summer reading. There's something about escaping into a new book that is, at once, exciting and relaxing.

One on my earliest memories is that of accompanying my father to our local library on a hot and sunny Sunday afternoon. I was barely big enough to carry my books and manage the wide steps at the same time. I remember, vividly, walking from the bright, sticky heat of that wide cement stairway into the cool, shaded, hush of the high-ceilinged, dark paneled, Victorian building. I lay the returning books on the desk then waved to my father and headed off down the dim hallway into the equally hushed and cool Children's Department. There, sitting at the miniature reading table with it's tip-tilted, varnished, mahogany book rests, I was in heaven. It was so quiet and peaceful and there were sooooo many books to choose from. I could barely contain my delight. My Dad could have left me there all day and I would, indeed, have been a happy camper.

Today, I feel the same contentment and pleasure as I pick out books for summer reading. This year's list includes:

1. Poetic Medicine: The Healing Art of Poem-Making by John Fox

2. presentationzen: Simple Ideas on Presentation Design and Delivery by Garr Reynolds

3. Come, Thou Tortoise by Jessica Grant

4. Savor: Mindful Eating, Mindful Life by Thich Nhat Hanh & Lilian Cheung

5. Passages in Caregiving: Turning Chaos into Confidence by Gail Sheehy

6. The latest mystery novels by Anne Perry and by Deborah Crombie

7. A re-read of some of Mary Oliver's poetry

What about you? What can you take from the bookshelf that will relax, restore, and refresh you as you take time out to re-create this summer?

Wednesday, June 16, 2010

S-l-o-w-i-n-g Down...

There is a secret bond between slowness and memory,
between speed and forgetting.

Milan Kundera

Yesterday was a busy day and I was rushed. Many phone calls and emails to return. Writing deadlines. Planning for fall workshops. And all the usual minutia of life. During the afternoon I had a great chat with a Vancouver social worker requesting a workshop and, in following up, I sent her a Speaker's Kit by email. Only I forgot to attach the Kit to the email.

It wasn't a big deal. I recognized that I'd forgotten the attachment the second after I hit the Send button - but it reminded me of Milan Kundera's statement about the relationship between speed and forgetting. Why was I in such a hurry? Where was the emergency? If I had approached the task more slowly, I would have taken half the time in the long run. And I would have saved the social worker the time she spent emailing me back to say that the Kit wasn't there.

David Kuntz reflects on the notion of slowing down in one of my favourite books, Quiet Mind: One-Minute Retreats from a Busy World:

As recently as a generation ago, ...
people lived their lives with a conscious realization of the balance
between slowness and remembering, between speed and forgetting.
They knew that leisure was a necessary part of a balanced life.
They knew that if you moved too fast you were bound to forget something.

We know it too, but only if we stop to recollect it.
Contemporary life does not afford us the intuitive awareness of our forebears.
It is, in fact, counterintuitive to a life in balance.
Unthinking acceptance of our culture's rate of speed is a terrible, yet common error.
These ... bonds must now be noticed with full intention,
and more, shouted from the rooftops.

There are many individuals and organizations now focused on "shouting from the roof tops" about our need to slow down. There are internet sites for Slow Food, Slow Travel, Slow Schools, Slow Living, even Slow Money. In fact, there's a whole Slow Movement born of our very human desire to not only avoid forgetting, but to make a deeper connection with ourselves and our lives. We want time to live life. If we run around at warp speed all day long there is no time for the things that matter - our own mental, physical, and spiritual health; our cherished relationships; our neighbourhoods; our environment; the natural rhythms and seasons of our lives.

There is much to be gained by slowing down but how does one do it? First, I think we have to be willing to give up some of our busyness and to grieve the losses that come in consequence. (Do we really have to go out five nights a week? Do our kids really need to be involved in more than one or two activities? Must we work ten hours of overtime every pay cheque?).

Once we've freed up some time, we can make choices about ways in which to slow down or pause during the day:

1. Breathe. Whenever you notice that you're feeling stressed, pause and take three deep cleansing breaths. And, as a form of prevention, pick a trigger - the ringing of the phone, the opening of a door or cupboard, getting into your car - and use it as a cue to take three more breaths.

1. Make a conscious choice to do less. Cut down your "to do" list to what's really necessary and let go of the rest.

2. Add more space. Schedule more time between tasks and appointments and, if you have to travel, leave earlier to get there so you're not rushed.

3. Disconnect from the electronic world. Shut off your mobile devices for a while. Schedule time away from your computer. It is hard to slow down when you're constantly checking your emails or answering your cell phone.

4. Be present. Practice being mindfully present to what you are doing or whom you're with. If your attention wanders, gently return it to the task or the conversation until you are finished. Notice and appreciate the beauty, the humour, the support and the life around you, whatever you are doing.

5. Spend time in nature. Be mindful of the seasons and the rhythms of the natural world. More than anything, these will teach us a healthy pace of do-ing.

6. Eat more slowly. Take the time to grow some of your own food, if that is possible. Prepare fresh food rather than refined meals whenever you can. Share the preparation with loved ones. And when it comes to actually eating, eat mindfully. Turn off the TV. Set the table attractively. Share the meal with others. Chew each bite sufficiently to actually taste its flavour and appreciate its texture.

7. Move more slowly. Unless you are exercising, walk, cycle and drive more slowly. Notice your surroundings. Your field of attention narrows as your speed increases, and widens as you slow down and that is safer for everyone. Try some walking meditation.

8. Consider slow travel. Engage more fully with the communities you visit. Make a "home base" when on vacation and travel by public transportation or other low-impact modes within a defined area. Visit spots enjoyed by local residents rather than following the guidebooks.

9. Explore slow parenting. Plan less for your children. Allow them to enjoy their childhood and explore the world at their own pace. Read books like Elkind's, The Hurried Child, and Carl Honore's, Under Pressure: Rescuing Our Children From the Culture of Hyper-Parenting.

10. For family caregivers. If you are doing long term, 24/7 caregiving and all this seems totally ridiculous, consider asking everyone you know to sign up on a rota to spend time with your care recipient, or to be available in the house, so that you can at least take a nap or read a book - slowly - undisturbed.

Tuesday, June 8, 2010

Trauma and Aging ...

Last month The Canadian Press reported that Canadian military chaplains are experiencing high rates of burnout and compassion fatigue. That, in itself, is not news. Military chaplains have been experiencing primary and secondary posttraumatic stress forever. What is new and encouraging is that the problem is being recognized and addressed at official levels.

My husband was a British Army chaplain who, within six months of signing up, was posted to active duty in the Aden conflict as the British withdrew from that country with the populace at their heels. In the years that followed, he occasionally told stories of scanning rooftops for snipers whenever he left his rooms, of comforting boys terribly wounded by the equivalent of today's IED's, of writing personal letters home to their families after they died and of driving exposed through the desert to bury them, protected only by a single gunner on the back of his jeep. (Chaplains were not issued firearms.) Over time, his body succumbed to the effects of the stress and he was sent back to England with chronic pneumonia.

Despite the impact of these experiences, my husband coped quite well, from a psychological standpoint, until his mid-sixties when he developed heart failure after a viral infection. This event, with its traumatic onset, triggered the same feelings of fear and vulnerability he had felt forty years before in Aden. (And as a child in London during World War II.) As his illness progressed, so did his posttraumatic stress symptoms. In fact, during the final months of his life when he experienced increasing sleep apnea, (periods without breathing that occur during sleep), he would vividly "revisit" Aden during the breath-less periods then "return", disoriented and frightened, to the present each time he began to breathe again. This cycle would continue for hours on end, exhausting and terrorizing us both.

Fortunately, I was aware of the "new" research of the mid 1990's, research which helped us to understand and cope with these harrowing episodes. These studies of older combat veterans, holocaust survivors and Dutch resistance fighters showed that trauma survivors who were otherwise functioning well could experience a late onset or worsening of posttraumatic stress symptoms secondary to the stress of physical illness or injury, changes in environment, or medical interventions. This was what was happening to my husband and it is important information for all of us to know for a number of reasons:

1. As World War II and Korean, Vietnam, and Gulf War veterans; immigrants of war torn countries; and other trauma survivors and their families age, we will see increasing numbers of older adults in our health care, addiction and social service systems affected by late onset or exacerbation of PTS symptoms. They deserve, and will require, knowledgable and compassionate trauma-specific diagnosis and care.

2. As more of these trauma survivors enter our support systems, the possibility exists that more helping professionals, volunteers and family caregivers will experience secondary trauma exposure, creating the need for more compassion fatigue resources.

3. As both groups - helpees and helpers - age, there is also concern that cognitive impairment could keep them from identifying the sources of their symptoms and working through their trauma. This could leave numbers of survivors acting out unresolved trauma because they are no longer able to understand or express it directly.

The moral of the story for us as caregivers? As a long term care aide once said, with tears flowing down her cheeks as I finished a talk on "Trauma and Aging"-

"Listen to her. If you have trauma to heal, do it now. You never know when it's going to be too late. I see it in my patients all the time. They're in pain but I can't figure out why or what to do to help because they can't tell me what's happened to them any more."

(Caveat - This doesn't mean that we should sign up to heal our lives during the middle of a caregiving crisis. It just means that we could all do well to recognize that posttraumatic stress can worsen with age and to plan to do some appropriate therapy when the time is right - a time that is preferably sooner than later.)