Self Disclosure & Smoking Cessation

I'm not really big on self-disclosure, especially in a patient-practitioner setting for many reasons. For one, I never want to be like this old colleague of mine, who presented transcripts of her sessions with a patient and always left me wanting to raise my hand to ask, "Wait, I'm confused...can you please clarify which one of you is the patient here?" It kind of annoyed the heck out of me to have to listen to her soliloquies at our weekly case conferences. We learn to be professional and to have well-defined roles and boundaries...strong iron clad professional boundaries that is. Clearly, she did not.

For the most part, patients don't direct the conversation towards me or ask me questions about myself. This almost never happens at the hospital where they've come out of thier way for a service, unless of course they are having a bad day and want me to have just as bad of a day as they're having. In such a case, they might berate me and tell me I'm useless...but then they come back the following week without fail, so at least I know it's not really me. Every now a then, I get a, "I'm doing fine, how are you doing?" which always surprises me and I have to take about a second to grab the word "well" from my vocabulary bank followed by a quick "so, what are we working on today?".

I've been doing some smoking cessation work over the last few months here at the VA. Most of the patients have no desire to quit smoking. The conversation usually ends with "I smoke about 2 packs a day and it doesn't really bother me, so I have no intention of quitting at this point...I may sometime down the line, but I'm good for now". We learned that if the patient has no motivation to quit, than we don't push the issue. The reason being that if they're not motivated to quit then we're not motivated to annoy them further because truth be told, checking in on someone about something they don't want you to be checking in on is just really freaking irritating.

And then there are those patients who say they want to quit, "I have all the resources (ie. patch, spray, gum), and I'm just waiting for 9/1/2010 or 10/1/2010 or 11/1/2010 to really stop." We learned that these patients tend to like the idea of quitting, but also are not motivated to really quit so we just treat them the same as the ones who are actually forthcoming with having no intention of quitting.

And then there's Mr. S, a married 48-year-old with 2 children spinal cord injury patient. He's been smoking for over the last 18 years and thought he should look into stopping after he was diagnosed with Chronic Obstructive Pulmonary Disease. Actually, it took a COPD diagnosis and maybe about an additional six 50-min sessions about his PTSD before he even acknowledged the possibility of quitting. "Smoking calms me down, takes the edge off, helps me function better as a husband and father, and helps me not think about my time in the service" he told me when I first met him. "I understand. But you know, smoking caused your COPD and this COPD can potentially kill you." He shrugged. I shrugged. And we never talked about smoking again until this week...

"So, I've decided to quit smoking" he said on Monday over the phone. "In fact, I already quit. I haven't smoked a cigarette in 2 days...I've gone cold turkey." I did some quick motivational interviewing around his decision and then expressed my concern for his going cold turkey so quickly. You see, I've learned that smoking is probably one of the hardest addictions for people to give up mainly because the pain of giving it up deosn't hit immediately, and when it does hit, it hits hard. "I'll be okay," he said, "I just wanted to let you know so we can talk about it on Thursday when I come in."

I guess I wasn't all that surprised this afternoon when he came in angry and somewhat disheveled. We started by talking about the weather and how he had gone to the beach with his family earlier in the week. He then told me that he hadn't slept much in the last few nights and felt consistently on edge snapping at his wife and kids. "I caved and had a few cigarettes yesterday I'm really beginning to wonder if it's all worth it and if I should just forget the quit smoking thing altogether." I told him that I knew it was hard for him, but I could see he was working hard and that he was doing a good job (this is probably the worst thing you can possibly say, but it's the only thing I knew to say). And then it came:

Mr. S: You know? What do you know? Do you smoke? do drugs? Have you gone to war? You look all clean and good, I bet you have no idea how it feels or what I'm going through. I'm in a wheelchair. I can't breathe very well. I don't sleep well, and now I gotta quit this thing that has kept me going for so long. What do you know?

I was completely caught off guard. It's been implied but I'd never been asked outright, the "what do you know?" question. I was quiet for a while wondering what it was that I did know...and then:

Me: Mr. S, you know you're right. I've never been on drugs or even touched a cigarette for that matter. I'm as clean as they come.........but believe it or not, I know what it feels like...I know what it's like to be so deep into something, to be so dependent on it even though I knew it could and would probably kill me. I know what it feels like to try and quit that same thing and feel absolutely crazy and out of my mind in trying to kick it...and I know what it feels like to fail repeatedly at quitting and then to have to start all over again. And you're right, I haven't gone to war and I'm not in a wheelchair...but I do kind of have an idea of what it's like to feel trapped...

He was quiet for a while and then asked me what he should do and what I would do. I didn't really know what to say at that point. I felt like I had already violated every rule in my book of nondisclosure.

Me: You keep trying and you accept that you'll fail a few or even many more times...and that it will hurt each time. And you'll have your good days and your bad days, but you keep trying anyways...because you have to believe that you're meant to be better than where you're at right now...and I believe that about you, that you can be better...and I think you believe that too because otherwise you wouldn't be here...

Thinking a Little on Haiti

My last annual just refused his psychological assessment. The 10 second meeting went something like this:

Me: Hi Mr. M, my name is Grace and I'm from psychology. I just have a few quick questions and you'll be all done

Patient: I don't believe in psychology, I think I'll pass.

Technically, he's not allowed to just pass on psychology. He needs to go through a complete annual evaluation with the Spinal Cord Injury physicians, social work, nursing, physical therapy, and psychology staff in order to continue having the VA pay for his pain medication, but since I don't like forcing anything on anyone, I respected his wishes. I'm not very good at being assertive when it comes to advocating for my own agenda...or in this case, the VA's agenda. Over the last few years, I've seen lots of people and somehow I've managed not to take anything personally and instead just shrug it off as "whatever, you do what you want".

Anyways, so since I have some extra time, I thought I'd take some time to write about my trip to Haiti. I've been back a little over and week and life has been pretty crazy since I got back last Monday and still continues to be. To be honest, I really miss Haiti...more than I thought I would which kind of surprises me. I'm not completely sure what I miss about it since I haven't really had time to process the whole experience. I mean it was hot...really hot and I didn't have much of an appetite the entire trip. Nevertheless, I really miss it. It was nice to not have to think about yourself all the time for a change. Part of me kind of wants to forgo the whole processing part because to be honest, I'm not really very good at feeling certain things. I've become better than I used to be, but the case still remains that I'm really good at thinking about things but not so much at feeling them. It seems I've become really good at not letting devastating things devastate me. In fact, I can't really recall when my heart was last wrecked by something.

So on the subject of being wrecked, I remember being really wrecked when I went to Bangkok in 2004 at an AIDS hospice where I got to hold a dying 3 year old girl in my arms. She was just about 1/2 dead and I don't think I could really handle whatever it was I was trying to handle. I remember having a really hard time with poverty in general even after I returned to the US, to the point where I had to look away whenever I passed a homeless person on the street. It was a conscious decision. I chose to look away and I feel like I've chosen to not let things wreck me anymore. In my early adulthood, I've come to realize that the middle road may just take a lifetime for me to find. It's safer to sit on one side and just think about the other...in depth and detail, but no matter how long or hard I let my mind wander over there, its still just a thought.

I like to think I've developed the skill to maintain a healthy distance from the pain I face on a daily basis, but I'm not really sure if it's skill, or just my unwillingness to really let myself feel involved. I'll admit that I wasn't all that involved emotionally while I was in Haiti. I was there to help and to serve and that's just what I did. I couldn't really speak with the natives and while I really wanted to hear each person's story, the language barrier and the numerous patients that needed to be triaged just didn't quite allow for it. Well, regardless I still miss it and kind of want to go back...

Resilience

In my four years of training...that's 4/5 with only 20% left , I've had the privilege of working with all different types of people. I've sat afloat in the home of a hoarder, accompanied an agoraphobic elder to the dentist, suited up in gown, gloves, and mask to assess the psychological functioning of a cancer patient in isolation, celebrated the 60th birthday of a transgendered man with paranoid schizophrenia & stage 4 metastatic breast cancer, waited alongside a diabetic 10-year old before sending him through a world class MRI machine. I've watched 3 people slowly fade and then disappear. The culprits: Cancer, COPD, and Cholecystitis.

"The work we do is hard", a colleague of mine once stated as she shared how she finds it difficult to refrain from becoming too attached. She asked me how I manage to remain uninvolved. I told her I didn't know, but that I did notice I have this uncanny ability to leave what I see, do, and say in the place I did it and only pick it back up when I return. I told her I thought it was what might make this profession perfect for me...that I could be passionate about but at the same time stay uninvolved and continue living my life at day's end. Slowly, I'm learning there's a fine line, the one that helps you maintain a balance between being professional and being human, the one that makes you a good psychologist and a great psychologist.

I've been working with Spinal Cord Injury patients at the Veteran's Hospital. I loved it from day 1. I loved everything about it: the interdisciplinary approach to care, being able to learn on my feet, the neurosurgery rounds...everything. I was still uninvolved, yet I felt like a true growing professional...until this week.

Mr. M came in for his annual evaluation at the SCI clinic on Tuesday. He was my last annual evaluation of the day. He had a diagnosis of MS w/cerebellar atrophy (which I had no idea what that was). I went in w/my clipboard and neuropsychological testing screens. The notes indicated he had expressed some problems w/his memory the previous year. I thought it might be helpful to get a better understanding of his possible cognitive decline. He was a pleasant looking man who was cooperative and smiled a lot. I shook his hand and introduced myself... and then he spoke. "HWWE---LLLLLO", he said slowly, exerting all his energy to greet me. I realized he had dysarthria.

In lieu of the pain in his lower body, the MS, the braces on his legs, the inability to manage his own bowel & bladder care, the fact that he had no living family members, he told me in long drawn out words that his only complaint was wishing people would take the time to listen to him while he worked his hardest to get his words out and that all he wanted was to have a conversation. I was speechless for a moment. I had an agenda that needed to be completed. I made a quick decision and in that moment, I put down my clipboard, boxed up my neuro testing kit, and decided to have a real conversation. The social worker came and went and I stayed w/Mr. M. I had a hard time understanding his words but 2o minutes into the conversation, I felt I could understand what he was saying. He was 85 and most of his good friends had passed. He said he was okay though. He liked to visit Walmart and wheeled into town almost everyday. He grew up in Washington state, but loved living in CA. He misses his parents dearly and wonders when it will be his turn to pass. I stayed with him for a while. He asked me if I had anywhere to be as the clinic closed at 4 and it was just about 5. I told him I didn't need to be anywhere important and in that moment I realized that I had crossed the line. Resilience is powerful thing. It's what keeps Mr. M positive through all the crap and puts me to shame when I catch myself thinking about what I wish was different in my own life. It's what gets me involved and what makes this work difficult for me. Resilience.

We talked a while longer and then the paratransit came. I walked him out to the van and said goodbye."Thank you for working w/vets", he said. 'Thank you for serving our country", I said.

Little Stranger Girl

There's a love he cannot hide
Though he waits in the line to fight
So he looks up to welcome you, his child
Little stranger girl, you are home tonight.

He reaches out a thousand miles
And sends his voice to where you lie
And in your dreams he carries you, his child
Little stranger girl, you are home tonight.

When you have grown, you may ask why
And you will read these words he writes
And they will say, I thank you, my child,
Little stranger girl, you are home tonight.

-Peter Bradley Adams

As Promised...Holes in My Teeth

I've been living a pretty quiet life lately...some might even call it boring. Not that I mind since I've always been a rather low key person. It doesn't take very much to keep me entertained or make me happy for that matter. I laugh easily and loudly. Lately, I've found that the best way to cope with a hard day or anxiety is to DANCE IT OUT in my apartment while my roommate laughs at my ridiculous means of decompressing (I've been trying to recruit her into my DANCE IT OUT @ the end of a rough day club, I think its finally beginning to work)...I learned this from Grey's Anatomy and decided I'd try it myself one day. Needless to say, it's worked miracles in my life. And while I feel like I've been this way forever, it's the holes in my teeth that remind me otherwise.

I had my foot stuck in some nameless rabbit hole for quite some time. My adolescent years were defined by an overwhelming drive for perfection which consequently lead to me finding what seemed to be at the time, such a well-fitting secure rabbit hole. And once I stepped, I was stuck...really stuck. At times, I found myself thinking there had to be some way out of that nameless rabbit hole, that even though I had made a choice to step in, the opening had not disappeared. Nevertheless, I remained stuck.

I spent just about my entire early adulthood staring at this bend in the road. The one that I just passed but couldn't get far enough to stop thinking about going back to. At times, I asked myself why I would even consider walking back towards that hell...just for a visit? And I always wanted to wallow at the bend for just a moment longer while I started off at a different path, the one I really wanted to take. The process went something like this: Maybe, I can walk it unti it circles back this place where I get to choose again. Maybe I can let go for just a moment more without caring. Maybe I can keep trying even if it mean I'll die trying. In hindsight, I see that even in all the "Maybe's" there was a hand that didn't let go of me. It never let go even though I thought it had because I never fell so far that I missed the last bend in the road--the one that had fought so hard and promised to bring me home...

It's been a while. My foot is out of that rabbit hole and has healed completely. I'm quite far from the bend, so far that I often forget what it felt like to have stared at it everyday. And I've come to graciously accept the hardest truth that I was never going to be the person I had always imagined myself to be. Even still, I feel shiny, happy, and new. And in those moment when I forget just how hard and painful the fight was to take my foot out of that rabbit hole, I have the holes in my teeth to remind me of where I got the strength and courage to do it.

Battle of Blog vs. (_____)

In the past 4 mos, I've had the persistent thought to start blogging more regularly. Not necessarily for the sake of my nonexistent following of faithful committed readers, but rather for the sake of allowing me to explore the thoughts underneath the hustle and bustle of what has become my life these days. So every week for the past 4 mos, there's been a range of battles: battle of blog vs. hustle, battle of blog vs. bustle, battle of blog vs. dissertation writing, battle of blog vs. Glee/Gossip Girl/Grey's Anatomy/How I Met Your Mother/CSI: NY/Friday Night Lights, battle of blog vs. sleeping, and of course battle of blog vs. googling phrases to answer questions I've had throughout my life such as "name of large ugly black long-beaked Kenyan bird" or "existing dwarf communities in California" or "commitment-phobic penguins", oh and of course "kangaroo mating techniques" (Note: the last two were inspired by my most recent trip to the SF Academy of Science). Alas, blog finally wins in the battle between blog vs. internship application essays.

To be honest, that's not entirely true. Deep down, I actually think blogging will help me write better essays. You see, I'm a bit of perfectionist when I write essays in that I never write the whole thing all at once, but rather spend an infinite amount of time making each sentence absolutely 'perfect' before moving onto the next. Kind of like how I just went back and reframed, reworded, and reread that last sentence five times...and how I just looked up the spelling on reframe, reword, and reread to ensure that there is no hyphen after the re.

Anyways...I'm supposed to be using this blog to answer the following question:

Please provide an autobiographical statement. There is no "correct" format for this question. Answer this question as if someone had asked you "tell me something about yourself." This is your opportunity to provide the internship site with some information about yourself. (Note: there are 3 other questions covering research interests, diversity, and theoretical orientation, but I'm going to pretend for now that they don't really exist)

To try and answer this question, I think I'll start by writing about how I have holes in my teeth...which will be the title of tomorrow's entry as there was just a battle between blog vs. cleaning room/project GLO-Get Life in Order and unfortunately the latter has won. Stay tuned non-existent loyal readers for next time's entry entitled "Holes in My Teeth".

Turning 28

I turned 28 this past Thursday. In all my years of existence, I've never dreaded a birthday year...until this year.

18 was the year I became an adult, the year I finally did not need my parents to provide consent on things. Since I had no plans of either purchasing cigarettes or pornography magazines, I decided to get a second hole in my ear. It was something I had kind of wanted to do for a while and since I didn't need my parents consent or authorization, I went ahead and did it. My dad flipped out a month later when he finally noticed my ears were double pierced. He forced me to take out the earrings (although by then, the holes were already permanent). 21 was the year I could finally drink alcohol. I was never really a drinker (still am not). To do something that I could not do at 20, I went to Dave & Busters after hours and received a complimentary birthday lemon drop drink. Tasty.

22,23,24 were so so years. I moved to San Francisco, was called a baby a few times. I figured 22-24 are when you fall into the "young & stupid" category. I never really felt like I did anything particularly "stupid" except for maybe be a little forward w/a guy that I had a developed a crush on (and when I say forward, I mean trying to drop a few obvious hints). I figured "whatever" since he was leaving. Okay at the time, I wasn't really thinking "whatever", more like I was thinking since I'd never even been flirtatious or impulsive, I might as well drop a few hints, take a chance that I would not normally take, especially since they were leaving...carpe diem right? In hindsight, I realize that line of thinking constitutes as " young and stupid". Perhaps the current line of thinking "whatever" constitutes a step past "young and stupid".

25,26,27 were good years. I was no longer naive. I had some experience under my belt. I could roll with the "big dogs" but was still young and cool enough for the "young and stupid" crowd. Needless to say, I don't think being in a long term serious relationship or a Ph.D program really qualifies under either.

So 28 will go down as the year I first began dreading birthdays. First of all 7 just looks better than 8. 7 is a slim and sleek looking number while 8 just looks round and loopy. I admit it was actually pretty hard watching the 7 turn into an 8. 28 is the year you enter your late 20's. For me, the hardest part is just accepting that I'm not where I wanted to be. I guess I had always envisioned certain things for myself at 28 and its hard to be reminded of everything you had hoped for, and see that it hasn't quite happened yet, and also face the possibility that it may never happen. I wrestled with God for quite a while on the day before my birthday. What was supposed to be a dissertation writing session ended up being a long walk around all of Pasadena. I think I just needed to figure out how to let go of all the disappointments I had tried to just bury and forget. I had made amends, forgiven, asked for forgiveness, but I think I just needed to make peace with myself, let go of the junk, and take those next steps forward.

As hard as it was to turn 28, I'll have to say my 28th birthday was probably one of the best. God has been so good to me. He has showered me with so many wonderful girlfriends and sisters in Christ. I needed them these last few months and they were there for me. Like the weeks I struggled so hard with making a decision about a 2.5 year relationship. I know it took courage but I don't think I would've been able to make my decision had it not been for all their prayer and support. There was also the morning after when I could barely see straight and CHa came over to make me lunch and keep me company through that first day of change and then the weeks ahead when all the rest helped me ease into the transition and realize how full my life was.

Thanks LBD entourage for all your love and support and for always showing me a good time when I need it. Thanks T for treating me to the best french onion soup and for your kind heart and always reminding me of how much I really have to offer. Thanks J & M for your many years of friendship and staying just as you both are. Thanks BFF for the Tim Keller sermons and books and also for the weekly long-distance prayers and honest conversations that go from serious to hilarious all within the same hour. Thanks CHa for taking me to Santa Monica Beach during the last 45 minutes of my 28th birthday and praying over me as I move forward through another year and for always being there to cry and laugh with me. Thanks Jesus for my family and friends...and for loving me just as I am whether I'm young & stupid or old & seasoned.

TIRED

"Please do not be cynical. I hate cynicism - it's my least favorite quality, and it doesn't lead anywhere. Nobody in life gets exactly what they thought they were going to get, but if you work really hard and you're kind, amazing things will happen." - Conaon O'Brien.

I'm doing okay. Something I realized is that I'm better and stronger this time around. It's true what they say, every experience changes you maybe not all at once or as fast as you'd like, but it does. I'm not angry or resentful. I still feel a little sad from time to time, but I never think "what if". I know it sounds cliche, but it's as though I've learned not to look back.

I've been wrestling a lot in the last few weeks...mainly with myself and also with God. I have trouble with disappointment. I've always had and I've never been able to master dealing with it properly. I usually just ignore it whether it be in the form of writing people off, convincing myself I have selective amnesia when in fact I know I have an impeccable memory, or pretending I just don't care when in fact I do. The truth is when I'm disappointed, I hurt and the hurt sinks deep into my soul. I try to bury it deep within hoping I'll forget about it or just get past it, but it's usually not the case. I recognize I hurt often and many times deeper than the average person mainly because I invest like crazy. It seems I'm incapable of investing just a little. I either give nothing or I give it all and then when I lose, I feel like I lose it all. Maybe this is why I don't gamble or play the stock market.

I've been trying to journal more. Today I wrote "Dear God, I'm tired". I am. When I look back at the last 2.5 years and the relationship, I just feel so exhausted. I gave so much. I went the whole 9 yards and back and though I know it wasn't a waste, I can't help but think "for what?" I took a mental snapshot of my life and suddenly, it was like all the disappointments were staring back at me. As much as I often don't want to admit it, I give a lot...friendships, academic pursuits, relationships. It's as though I just don't know how to not give 150% to the things I decide to give to. When I think back at how hard I've worked in and at life, I can't help but just feel tired and wonder "for what?" Sometimes, I wish I could just be one of those people who can just go with the flow, invest along the way, but I'm not. It's like everything I do needs to be deliberate and intentional and so I either go all in or fold before I even get to the starting line.

Dear God, I'm just so tired. I know I'm too young to feel so tired, but I really do. I'm so tired from always giving my whole heart, from always believing so much in things, from working so hard at things, from trying so hard at everything. My soul aches for You. Uproot the disappointment I've sown. Don't let the bitterness take ahold of me. Help me not to be so afraid to keep giving. You are faithful and have been my entire life...help me not to falter now and to continue having faith even though I feel weary. I want to be able to wake up daily and delight in the greatness of who You are. Please help me continue believing in great things...

Come to the water you who thirst and you'll thirst no more.

Come to the Father you who work and you'll work no more.

And all you who labor in vain, and to the broken and shamed...

Love is here

Love is now

Love is pouring from His hands, from His brow

Love is near, it satisfies...

Streams of mercy flowing from His side

Cause love is here.

Starting Over and Getting Lost

It's a new week. I went to LA/OC this past weekend to get away from the Bay. It was nice to be in the warm sun and to spend some quality time with good friends. I got lost running around Pasadena and ended up running 11-12 miles are so. I kind of liked being lost. I would've run a lot more, but I had to be back by a certain time

To be honest, I'm not really sure what to write about or how to start. This whole starting over thing kind of sucks. I know it's the right thing, there's no doubt but I'm just not sure how to proceed with my life right now. I get sad from time to time, but I'm not devastated or breaking down. I didn't think I would be. I feel really lost. I had/have all these plans of moving forward, focusing on my dissertation, spending time in the Word, repairing my soul, but so far it seems I've been getting lost everywhere. I can't seem to get past the first few paragraphs of my dissertation because I keep getting lost in my thoughts. Ironically, I'm writing about rumination. If only, I could stop ruminating myself. I also keep getting lost in my Bible. I'm finding that reading the Bible is like writing a dissertation-there are so many chapters and sometimes I just stare at it and think "I just can't". I'm having a really hard time concentrating all around.

What's interesting is that at any given moment, I'm not really sure how I'll feel. This isn't because I don't feel anything at all, but more because I feel all sorts of things. I feel sad, I feel angry, I feel regretful, I feel hopeful, I feel disappointed and discouraged, I feel okay and then it starts all over again. I guess it's an improvement from my last break up where I felt nothing for an entire month and then when I finally started feeling things, I was so scared that I just shut it all off...that manifested really well for the next few years. One thing is for sure, I feel loss-a strange void that won't go away. It feels like this huge part of me is missing and when I explore what it is, I know it's the part that I gave away. When you make a choice to love someone, you give a piece of yourself away and when things don't work out, you want that piece back, but you can't really get it back. There are so many moments when I wish I could just forget.

I sit with people almost everyday. I learn about their lives and I journey with them for the next few months not always by choice, but because I have to. Thus far in my career, I've lost two people. One I barely felt, the other I let myself grieve for because I walked with him for many months and then had the privilege of being there to the very last moments before he died. I don't know if I kept going because I had to or because I didn't really let myself experience the loss. Maybe I didn't give a piece of myself away. It's different taking in what people tell you rather than giving parts of yourself away like you do in a relationship. Some patients, I really do love and then there are those patients where I just can't because if I did, it'd be hard to do my job.

People say to take it one day at a time and that's what I'm trying to do. I'm trying to do what I need to get done, I'm trying to focus on God and the things He has for me in this life. I want to be better and I want to push through, but I confess there are a lot of moments when I just can't. Instead, I'll look for a distraction. I know He wants to help me feel whole again and fill my soul, but I confess that more often than not, I sit there and think "I just can't right now". I know it's the only place I can go and so I'll just keep trying because I know even when I can't, it's still okay.

Painfully Right

“I have heard it said that the longest journey in life is from the head to the heart. Another way to say the same thing is that the spirit is willing but the flesh is weak. Yet another aphorism of our time is that beginning well is a momentary thing; finishing well is a lifelong thing. All of these point to one reality—our knowledge and our response are not always in keeping with each other.” Ravi Zacharias

It has been a really hard two weeks for me. I’m the type to feel things intensely yet at the same time ignore such feelings. I rationalize and think because I don't want to make impulsive decisions and commitments. My close friends can easily attest to how I default to invoking logic to my decision making process before I'd ever consider my heart or gut. I think its because I’m aware of just how uncertain emotions can be and how they can be deceiving and so I’m extra cautious that I don’t act on my heart or gut about things. Instead, I try to make sense out of things and do what makes sense. I just get so worried that I would act foolishly or unwisely. Interestingly, this has been the most consistent critique I’ve received from my clinical supervisor at the hospital. “Grace, you’re a competent clinician but you need to trust your heart on things and put yourself out there during session. You hesitate or submit to convention a little too often.” It is definitely one of the markers of a master clinician they just seem to have a way of knowing.

In this case, I did just seem to have a way of knowing. I've known for over a year, but I just had a hard time trusting it. It was this strange feeling that had become all too familiar. It would often come during my 9 mile deliberations with God...back and forth, "is this the one? I want it to be. Please, I can't go back out there, please just let it be the one". It wasn't and I knew, but it was so hard to accept and when I finally realized, I felt like I was making the hardest decision of my life. I wanted it to be enough. I wanted to be okay with what I had and not want more, but I did want more. What I was most afraid of is that I would never be able to find "more" and so I wanted to be okay with enough. "It's good enough, please make me okay with good enough or please make this more".

I prayed so hard for the moment, and then it just kind of came...the conviction. I know I did the right thing. I know it was the right thing because it was so painful and the more painful it was, the more I knew it was the right thing. I really didn't want to, but I knew I had to. I know I was never made to just be okay with enough, but I think I just wished I was.

They say the first day is the hardest. I woke up kind of forgetting it happened, but then I remembered. So I spent my entire morning sitting in front of my very broken dissertation being very broken. I'd breathe, type a few lines, and then go back to being broken all over again. I know it's okay to be kind of a mess, but it just feels so painful...and the more painful, the more I know that it's the right thing.

You are my candy girl...

Last Wednesday morning, I spent 20 minutes standing in the rain outside Candy's door. My left hand w/a fist against her door. My right hand repeatedly pressing the redial button on my cell phone. She didn't answer, neither the phone nor the door. "Candy", I tried calling out through the door. I know it probably wasn't the smartest thing, to be standing on the corner of a street in Bayview Hunter's Point for 20 minutes by myself with the entire liquor store crowd watching me from across the street. I didn't want to stay, but I didn't want to leave either. I know it's a problem of mine, not really knowing when to throw in the towel. It was raining hard so I walked back toward my car, careful not to make eye contact with the liquor store crowd even though I could feel them watching my every move. I didn't see Candy that morning. I wondered if I ever would again. It was just an unpleasant feeling in the gut.

Candy is the newest addition to my caseload. She is a 59 year-old transgender African American w/metastatic breast cancer. The doctors say she has less than a year left to live. It's my job to help her make peace with her life, to cope with the excruciating pain she experiences from the cancer, and to support her as she faces the rest of her life. I try my best, but its hard because she's schizophrenic and developmentally challenged. I wonder how it is that this person I've really come to grow fond of has so much working against her.

Every session she is the same. Manic, disorganized, tangential. Through her pressured speech, I've slowly been able to piece together her life...all 59 years. There's her earliest memory of being told that her father tried to suffocate her during her infancy...twice. Her mother saved her and since then has always been God, capable of giving and taking away life. There's the magic trick, the one where the boys stuck her in a cardboard box and stuck sharp sticks through thinking they could remake the swords through the box trick. There's her expulsion from jr. high, how she was told never to come back to school after refusing to play football with the boys. And then there's the incident at the country club, where she was fired for walking through the front door instead of the back door. Somewhere between dressing drag in Hollywood and losing her teeth to the police in Oakland, there was a trip to Tijuana for the $50 silicone injections. And then there was the day she learned she had breast cancer. "It's leaking all over my body" she told me, "into my bones, back, all over, just all over".

I'm fond of her, she's a wealth of knowledge, a walking account of the civil rights era, a real life "Precious", a detailed character from a James Baldwin novel. Even so, I'm not going to pretend I enjoy our visits because I don't. She hurls graphic descriptions at me w/her brother's "doped up girl" taking a hammer to his knees and her mother dragging her out into the snow screaming "fag". I don't always feel like I can take it, but I do anyways.

She tells me she loves herself and her mother and doesn't care about anyone else. She believes in Jesus and the Baptist radio preacher, the one who tells her she's damned. "I know I'm going to hell" she says, "I'm a homosexual, but you know I haven't really had sex with anyone in a really really long time I try not to indulge in sin". I'm speechless. I want to know why she listens to the radio. I even try to convince her to stop. She shakes her head. "Excuse me, I listen everyday...every morning, because it feels good to know Jesus is out there for me and I hear Him through the preacher I am a believer of Jesus Christ I've always been I went to Sunday school read the Bible Jesus loves me but I'm going to hell oh well but I know my momma will be just fine so I feel good". I want to cry, but I can't. I want to run, but I can't. So instead I say, "Candy, girl you're right, Jesus does love you...so much" and then I squeeze my eyes shut for a few seconds.

We filed a missing person's report on Candy yesterday. I hadn't heard from her and neither had the case manager. I'd been thinking about her all week. She's tangential, disorganized, not the best at reaching out, but she's always picked up her phone and answered her door. Not an answer for 6 days, neither phone nor door. "Candy, girl where are you? Jesus does love you...so much".

Loving the Elderly...

In June 2009, President Obama proposed a cut in Medicare benefits to help cover the uninsured. A month later, Charles Mann described the effects of the national trend toward increased longevity in his article “The Coming Death Shortage”. In November, the Senate voted to reduce home health-care services for seniors. At the same time, the demographic profile of the United States, with its rapidly aging baby-boomer generation will become even more elderly-concentrated; the U.S. Census Bureau predicts in 2030, 21% of Americans will be age 65 and older. As the older adult population constitutes one of the fastest growing populations, the need for addressing its mental health concerns grows ever more urgently. With ageism creeping into the health reform debate and the continued perception that it is shameful to be mentally ill, the lack of initiative to properly care for these members of our society will have serious consequences on the mental health of our nation.

Elderly Asians are a unique subpopulation within the aging population due to their rising numbers and the particular challenges created by their cultural legacy. (It is expected that between 2000 and 2030, the Asian elder population will quadruple from 800.000 to 3.2 million.) Because of this, my long-term career goal is to lower the barriers of access to mental health services for minority elders, especially those of Asian descent. I want to increase awareness of mental health issues among Asian communities while educating healthcare professionals about the unique cultural context of such issues. I plan to do this by creating culturally appropriate materials, providing referral guides, and training primary care providers on how to conduct effective screenings and interventions to Asian elders. Furthermore, I want to work on integrating mental health practitioners into primary care settings and eventually implementing the standard of a single door of entry for comprehensive physical and mental health.

My interests in both the minority experience and racial and ethnic disparities can be traced back to literature. Through detailed first-person reflections created by minority writers like Toni Morrison, James Baldwin, Amy Tan, and Jumpa Lahiri, I came to see how one's identity is forged through cultural, ethnic, and social contexts. The biography, Finding Iris Chang impressed upon me the necessity to study the stigma of mental illness within a sociocultural context in order to understand its origins, meanings and consequences. With this in mind, it is no surprise that my graduate studies focus on health care disparities and policy for minority elders.

During my first year, I was involved in a project that sought to identify the existing barriers for minority elders in utilizing mental health services. Through interviews with service providers, it became clear that minority elders face severe barriers that prevent them from utilizing mental health services. For older adults, more expensive private pay programs are more available than community-based programs. This presents a challenge to minority elders as many lack the educational and financial resources to access such programs. My volunteer work with City Team San Francisco – a non-profit organization serving the poor and homeless – illustrated both the reality and gravity of this situation all the more. I saw firsthand how minority elders are more likely to face poverty, live in low-income housing, and have poorer access to benefits and pensions in comparison to their non-minority counterparts.

While similar risk factors for depression exist for the elderly, certain factors compound that risk for minority elders. One factor is language. In conducting therapy in Mandarin with Chinese elders, I came to realize that language issues are vital to the delivery of mental health services. Many Asian elders speak languages with no equivalents for words like depression. Others lack the communication skills needed to access resources for preventative care. Cultural context further complicates matters. I noticed that Chinese elders stigmatize mental health problems and tend to equate common, treatable depression with insanity. This stigmatization causes many Chinese elders to somaticize emotional problems and look to other explanations for depressive feelings; they seek medical help only as a last resort. Finally, mobility is another obstacle. By conducting psychotherapy in nontraditional settings—homes, residential communities, day programs, and hospitals—I witness how physical constraints isolate minority elders and prevent them from accessing proper care and services.

Identifying and understanding mental health service barriers for minority elders challenged me to think about developing effective treatment approaches for this demographic group. After careful consideration, I decided to evaluate the delivery of mental health for minority elders in the county of San Francisco. San Francisco has the highest percentage of older adults in any national urban area, with a largely Asian sub-population. Through research and agency visits, I discovered that the ratio of available programs to people in need of services is too low. Next, I interviewed mental health workers and case managers at the San Francisco Department of Public Health in order assess the service needs for Asian elders. I found that the most prevalent health issue facing Asian elders is late life depression. Many Asian elders immigrate to the U.S as adults and suffer from the stress of relocation and adjustment to a completely different culture. Furthermore, many have to cope with prolonged separation from family members or are confronted inter-generational conflicts between the older and younger generations.

My clinical and research experiences have led me to conclude that effective treatment for minority elders cannot occur without employing culturally competent practices. Working with a diverse older adult population at a community-based organization has increased my understanding of culture-specific manifestations of distress, coping mechanisms, and help-seeking patterns. For example, I noticed that Asian elders prefer to discuss concrete solutions to problems rather than negative emotions. They are more likely to experience physical pain in response to stress and seek help from primary care physicians. As such, the need to reframe culturally sensitive terms such as “mental health” into “wellness” is critical to the clinical treatment and assessment of this population.

My desire to become a psychologist who focuses on ethnic minority health disparities began with literature, news stories, and statistics. In my quest to understand the causes and consequences of such disparities, I discovered that geriatric services for minority elders, especially for those of Asian descent, are an unmet need that is growing quickly and will only intensify over time. Furthermore, my professional experiences have convinced me that one must address the mind and body collaboratively as mental health is an important component to managing most health problems. I believe shifting toward the use of interdisciplinary or collaborative care models to provide psychological services to this population in a primary care setting, can increase prevention and improve both mental health and health outcomes. Through the Mental Health and Substance Abuse Services Predoctoral Fellowship, I hope to contribute to the field of ethnic minority geriatric mental health by providing community-based assessment and intervention services to minority elders, teaching primary-care providers, conducting research, and eventually becoming involved in health-care policy development.