Calm...

While walking in Santa Barbara, CA earlier this spring, I was surprised to see that the street banners, rather than announcing a local festival or naming a given neighbourhood, bore the outline of a little girl's face, a heart, a home and the single word, "Calm".

"What a wonderful idea!", I thought, as the tension melted away from my neck and shoulders. Had it been that city's conscious intent to create an atmosphere of peace in the downtown core? I don't know. But I do know that every time one of the banners caught my eye over the next few days, I experienced the same quiet sense of calm.

What, exactly, does it mean to be calm and how do we achieve this illusive state? To answer these questions fully, I will direct you to Babette Rothschild's excellent book, Help for the Helper: The Psychophysiology of Compassion Fatigue and Vicarious Trauma and Peter Levine's seminal work, Waking the Tiger: Healing Trauma. To give you the short answer, I invite you to read on.

The Autonomic Nervous System (ANS) is the part of the nervous system that prepares us to fight, flee or freeze in response to a demand or threat and then to calm down afterward. The ANS has two branches, one that creates arousal to meet the threat (the Sympathetic Nervous System) and one that reinstates calm once the demand or threat is dealt with (the Parasympathetic Nervous System). Working in tandem, these branches create the arousal cycle described by Peter Levine:

- "We are challenged or threatened

then aroused;

- the arousal peaks as we mobilize

to face the challenge or threat

- then, the arousal is actively brought

down, leaving us relaxed and satisfied."

It is important for anyone who has experienced trauma personally, or through caring for others, to be aware of the signs of ANS arousal (fast shallow breathing, quicker pulse, dilated pupils, pale skin, sweating) and the signs of ANS calm (slower deeper breathing, slower pulse, flushed, dry, warm skin). Learning to be aware of our increased arousal is the first step toward reinstituting calm.

Some strategies that can help us to return to a state of calm after a period of arousal include:

1. Arousal awareness

Learn to become mindful of your level of arousal by carefully noticing your internal physical state - the signs listed above, areas of tension etc. Then, practice noticing how that baseline changes when you remember something pleasant in your life or when you anticipate something mildly unpleasant. Move back and forth between the two states, a few seconds at a time, until you get a sense of how varying levels of calm and arousal feel in your body. Use this knowledge to assess your arousal whenever you're feeling uncomfortable. ("Calm" post-it notes, placed strategically at home and in your office, can be a good reminder to check in.)

2. Reducing general arousal

You can reduce your overall level of arousal, over time, through meditation practices, centering prayer, reducing your trauma input (ie how much trauma you see on TV, in the newspapers, in your work), engaging in personal therapy to resolve past traumas, and keeping your muscles fit. ("Relaxed" or lax muscles and "calm" are not necessarily the same thing. We may need a degree of "friendly tension" in order to manage our stress.)

3. Learning to put the brakes on

It is important to know different strategies for "putting the brakes on" when your level of arousal gets uncomfortably high. (This level is different for each of us.) A couple of these include:

(a) Using Peter Levine's instructions for Trauma First Aid to complete the arousal cycle and calm yourself after confronting a traumatic situation. (January 12 ,2009 post)

(b) Finding a Sensory Anchor to which you can retreat when feeling too aroused.

A sensory anchor is an internal image of a safe place/situation. Choose a memory of something pleasant that makes you feel safe and calm. (Don't look for the perfect memory because almost everything can have a negative association if you look hard enough.) Awaken your sensory memory of that place or situation. How does it look, smell, feel, sound, taste? Notice your body responses - has your calm increased? If so, practice switching from mildly unpleasant memories to your safe anchor until you can switch quickly from arousal to calm. (Be patient. As with any skill development, this will take time.)

These are just a few of the ways we can return to the calm I experienced in Santa Barbara. I invite you to try them out and to continue looking for ways to increase your own calm as you care for others.

Chronic Sorrow or Depression....?

This morning, I read a piece on family caregivers in the New Brunswick, NJ, Home News Tribune. It quoted an article in the American Journal of Public Health saying that family caregivers experience depression at a rate six times higher than non-caregivers.

I wondered, as I read the newspaper piece, whether the researchers had considered chronic sorrow in their assessment of the caregivers' moods? Would such a differential diagnosis have altered their findings?

For many of my caregiving years, I countered the concerns of my family and friends with an emphatic, "But I'm not depressed!". It's true that I had no energy, but who would if their sleep was interrupted every night? And I cried whenever I found a moment of quiet, (usually in my car driving somewhere), but I also had days of intense pleasure and beauty. My weight had gone up but that was because I was eating copious carbohydrates to counter the constant tiredness and I had a foot injury that had interrupted my usual exercise program. As far as I could tell, I wasn't feeling much differently from anyone else who was caring, long term, for an ill family member.

When I finally came across the writings of American psychologist, Dr Susan Roos, (Chronic Sorrow: A Living Loss), and of the Nursing Consortium of Chronic Sorrow Research I breathed a sigh of relief. They were describing my experience exactly and they weren't calling it depression.

Chronic sorrow is neither clinical depression nor chronic grief. Rather, it is the normal, but often unrecognized or misdiagnosed set of grief responses experienced by people with chronic conditions and the people who love them. Because this chronic condition is ongoing, so is the sorrow. Susan Roos describes this endless loss as a "living loss" that persists until the person with the chronic condition has died.

At the core of chronic sorrow is the aching discrepancy between our perception of how life is and "how it should have been". This discrepancy leads to a sorrow that is profound, pervasive, and periodically very intense.

Contrary to the experience of clinical depression, though, our daily functioning is rarely affected. We maintain access to a full range of emotions and our spirals into intense sadness are intermittent in nature, often triggered by anniversary dates, missed developmental milestones or recurrences or worsening of our loved one's condition.

Because the source of our sadness is not "resolvable", neither is our grief. We can't expect ourselves to "get over it" or "just get on with our lives". Antidepressants are not the answer unless we're actually depressed. Nor is psychotherapy focused on uncovering the traumas of our childhoods. (Though this can be helpful at another time.)

What many of us find most helpful is "companioning" with empathic support and help with problem solving. Someone who will "be" with us, in our sadness and in our joy. Someone who will walk the journey with us without trying to fix the unfixable.

That is not to say that therapy is unhelpful. A skilled grief and trauma therapist who understands the difference between depression and chronic sorrow can be an excellent "companion" and a godsend. While I don't believe it is possible to "cure" chronic sorrow, it is possible to find healing in the journey - a resolution of posttraumatic stress symptoms, the development of wisdom, a refined appreciation for life, the growth of spirituality and meaning - and that healing can be our goal.

(Caveats:

Please remember:

1. Chronic sorrow can lead to clinical depression so, if you feel unsure about your mental health, ask your medical professional to assess your mood - after reading about chronic sorrow.

2. Never stop taking antidepressants without first consulting your physician.)

* Photo by Bigstock Photos

Caregiver Injuries....

It's a beautiful Spring Saturday morning - sunny, clear and bright with the scent of lilacs, azaleas and rhododendrons wafting in on the cool air from the garden. I'm sipping a mug of my favourite Dutch coffee and savouring the pre-lawnmower quiet.

I haven't posted here for the past week because a "caregiving injury" has severely restricted the use of my right hand. I am cat-sitting for a few weeks and the poor old thing has renal failure which necessitates frequent feedings and the administration of a small pill every morning. 

During one of our pill-encounters, Si nipped my finger, leaving an all but invisible puncture wound. By six o'clock that evening, my finger (and the rest of my hand) was hot, red, swollen and exquisitely tender and off I went to the clinic for antibiotics and a tetanus shot.  The young doctor there informed me that about 80% of cat bites become infected, some very quickly and seriously. If my infection increased at all I was to go to the emergency department for IV antibiotics. (!) Fortunately, the oral medications have worked well and I'm able to type quite comfortably this morning.

All this did make me think, though, about how often caregivers are injured while doing simple, everyday caregiving tasks - sometimes because we're tired, sometimes because we're preoccupied  and sometimes because we lack information about what we're doing.

While caring for my husband during his bed-bound years, I spent much more time than usual on my feet at home. Like many people, I tended to kick off my shoes at the front door and go barefoot or push my feet into a pair of comfortable old slippers. Little did I know that spending hours on my feet in poorly supporting foot wear would result in a case of bilateral plantar fasciitis that took two years and hundreds of dollars (orthotics) to heal! So, here's a piece of advice that you probably won't find in any other writings for caregivers - Be sure to wear well-fitting and supportive shoes whenever engaged in caregiving that requires extra time on your feet. It's well worth the effort!

Also worth the effort, whether you're a helping professional or a family carepartner, is taking the time to assess the things you do regularly while caring for others. 

- Do you  make an effort to stay in the moment, present to the task at hand, or are you already three steps ahead, planning for something else entirely? 

- Are you practicing good self care so that your body is fit and well rested for the tasks you have to undertake?

- Are you asking for help when you need it? (It can be annoying to wait for someone to help you lift a wheelchair into the trunk of the car, but not nearly as annoying as being laid up for six weeks with a back injury!).

- Is your work area set up for good ergonomic functioning? 

- Do you know how to do caregiving tasks correctly - good body mechanics, proper care of needles and other sharps, correct procedures for handling aggressive behaviour? Again, asking for information can save injury both to yourself and to your care recipients.

So, if we all do our best to remain mindful, fit and rested, and informed in our caregiving, we are far less likely to become numbered among the "cared for". Is there one thing you could change this week to make your caregiving safer for you? 

      

What's Up....?

May has been a busy month and I have just finished the last of the workshops scheduled for the Spring. As always, I have been deeply moved by the response of family caregivers and helping professionals to information about Compassion Fatigue and Chronic Sorrow. Heads nod and eyes tear as people come to understand that their distressing symptoms are normal responses to trauma and loss.

My plans for the summer include some vacation time on Vancouver Island and in Oregon state and also a lot of writing. In the pipeline are articles for the Well Spouse Foundation and the Victoria Caregivers Network Society and I will be starting an ebook on Chronic Sorrow for family caregivers and the helping professionals who support them. In order to have a base from which to distribute the ebook, there will also be a website to design.  And the weekly blog posts will continue for the weeks that I'm in town. Fortunately, I'm, one of those people who still writes with pencil and paper (!) so I can go pretty well anywhere from mountaintop to sea shore to do my writing and I expect to do both.

The first fall workshop bookings are coming in now so, if there is a particular date that would work best for your organization, please feel free to contact me to hold it for you.

  

BC Family Caregivers Week - May 9 - 13...

This week is Family Caregivers Week in BC and I am fortunate to be taking part in the Caregivers Program for the Family Caregivers' Network Society in Victoria on Friday and in the annual Caregivers Association of BC Caregivers Fair at Robson Square in Vancouver on Saturday.  It is always a privilege to speak to family caregivers and, in turn, to learn from their stories and experiences. I'm really looking forward to the weekend.

I think that Caregivers Week is a good time to remember that family caregiving is not just confined to middle aged women caring for aging parents, though that is certainly a large and growing segment of the caregiving population. We tend to forget that there are millions of young adults and children who are providing part time or full time care to grandparents, parents, siblings and, in some cases, to their own children. 

While countries like England have focused on the needs of "young carers" for several years, we in North America have been slower to acknowledge their important contribution to the stability of families coping with chronic and serious acute illnesses and injuries. These young people have all the needs of older carepartners plus the added needs of their own developmental stages.

As Carol Levine, director of the Families and Healthcare Project at United Hospital Fund and lead author on a study of young adult caregivers, said in 2005 - 

To provide any kind of meaningful assistance to young adult caregivers, who are

at a critical stage in their life and development, we need to carefully consider the

impact of their responsibilities on employment, education and social life. Services

developed for older women are not going to be appropriate for younger men and

women.

She goes on to say that -

The young adults who are caregivers now are, we suggest, only the first wave

of the future. With social changes such as delayed childbearing and smaller

families, aging parents will have to look for help to children still in their 

formative years. The...grandparents currently raising one or more grandchildren

will need help when these children are in their twenties. We speculate that, in the

future , care recipients will be even older than they are now and caregivers will be 

even younger. What this may mean for a youth-oriented but aging society is a 

crucial, but an open, question.

As we move ahead in acknowledging and creating programs to support older adult carepartners, let us not forget the needs of this younger and at least equally vulnerable group.    

Compassion Fatigue Recovery...

Recovering from Compassion Fatigue can be a slow and difficult process, particularly when there is a significant amount of personal loss and trauma, (primary traumatic stress), to work through. At the same time, it is a journey that can yield true joy and wellness if we're willing to do the work of becoming self aware and self caring.

Yesterday was one of those days of joy and wellness in my own recovery process.

Since sunny childhood mornings spent weeding with my mother, gardening has been a great source of peace, creativity and comfort in my life. But after the experience of maintaining a trauma therapy practice while caring for my husband and then for my mother during her brief terminal illness three months after his death, I didn't want to take even one step through the garden gate. The thought of caring for anything or anyone in any way was overwhelming. I couldn't even care for myself very well.

That was almost five years ago and so much has changed since then. With intention, effort and patience I made space for my body, mind and spirit to heal. I found a good grief counsellor to be a companion and "emotional container" as I grieved and, later, I did body work to release the traumatic stress stored in my muscles and sinews. I walked every day by the Lake, allowing Nature to do her healing work. I meditated and prayed and I waited in the stillness until I was able, finally, to store enough energy to interact with others again. Then I began to spend time with selected loved ones who gently led me back to life. I journalled, I listened to Mozart and Abba and I read my favourite authors and poets. Gradually, I remembered the things that authentically refresh and sustain me.

But, still, I didn't want to garden. The very thought of it made my chest tight and and my limbs heavy  with inertia. As I sat with these feelings, I came to believe that the return of my desire to garden would announce my emergence from this last severe episode of Compassion Fatigue.

So, imagine my delight when I woke at 4:20 yesterday morning with plans for springtime plantings swirling about in my head. New roses to replace those damaged by the winter's cold. More container vegetables this year. Sweetpeas for the trellises. I was up and perusing gardening books by 5:00 and at the garden center when it opened at 9. This morning, there are three new bushes in the rose garden and a row of sweetpeas along the fence. This afternoon, the tomatoes and swiss chard will be bedded and the first batch of mesclun sown.

But, best of all, is the knowledge that in waiting and trusting my own process, I have allowed my energy to accumulate to a point of abundance again. I have healed and filled myself up and now that energy can overflow into healthy caregiving - of both plants and people. It has been more than worth the effort and the wait and now I have my garden as both a source of joy and beauty and as an early warning system for encroaching compassion fatigue in the future.

  

 

  

  

Personal Boundaries....

When we grow up in families of trauma, we may lack the opportunity to develop healthy personal boundaries. (A personal boundary is an imaginary line of demarkation between me and not me.). When our boundaries are poorly differentiated, we run the risk of overextending ourselves in our helping roles.

As James Miller expresses so clearly in The Caregiver's Book -

To be close, you must establish boundaries.

When the needs of someone you care for are great, 

or when you have become part of the other's life in so many ways,

you may desire to draw as close as possible.

You may be inclined to keep that person always at the forefront of your thoughts.

You may try to keep yourself always within easy reach of their grasp.

You may find yourself almost merging with the other person,

so whatever happens to them happens to you.

Whatever they feel, you feel.

Whatever upsets them, upsets you.

Whatever their pain, you take it on as your own.

Identifying so completely with another

is an ideal some caregivers have sought

But it is less than ideal.

We all need healthy personal boundaries.  We need to be able to maintain a separate self with our own experiences, limits, sense of privacy, supportive relationships, and times of reprieve and refreshment.  When we create a separate space for ourselves, we allow the people we care for to have their own space as well.  As Miller says, -

They need it as much as you - perhaps even more. For they may not have the 

strength or clarity to create that space on their own.

And as Rainer Maria Rilke has said, -

Love consists in this:  That two solitudes protect and border and salute each other.

Are there ways that you can create your own space today? Define your own limits? Take some time out? Nurture supportive relationships? It will make a healthy difference to you and to all those for whom you care.