Suffering the Slings and Arrows Of Outrageous Fortune: International Perspectives on Stress, Laughter and Depression

Suffering the Slings and Arrows of Outrageous Fortune International Perspectives on Stress, Laughter and Depression

At the Interface

Series Editors Dr Robert Fisher Dr Margaret Sönser Breen

Advisory Board Professor Margaret Chatterjee Professor Michael Goodman Dr Jones Irwin Professor Asa Kasher Dr Owen Kelly Revd Stephen Morris

Professor John Parry Dr David Seth Preston Professor Peter L. Twohig Professor S Ram Vemuri Professor Bernie Warren Revd Dr Kenneth Wilson, O.B.E Volume 31

A volume in the Making Sense Of: project ‘MSO: Health, Humour and Healing’

Probing the Bounderies

Suffering the Slings and Arrows of Outrageous Fortune International Perspectives on Stress, Laughter and Depression

Edited by

Bernie Warren

Amsterdam - New York, NY 2007

The paper on which this book is printed meets the requirements of “ISO 9706:1994, Information and documentation - Paper for documents Requirements for permanence”. ISBN-13: 978-90-420-2148-8 ©Editions Rodopi B.V., Amsterdam - New York, NY 2007 Printed in the Netherlands

Welcome to a Probing the Boundaries Project Suffering the Slings and Arrows of Outrageous Fortune a ppears within the Making Sense of: Health, Illness and Disease project series of publications. These projects conduct inter- and multi disciplinary research aiming to explore the processes by which we attempt to create meaning in health, illness and disease. The projects examine the models we use to understand our experiences of health and illness (looking particularly at perceptions of the body), and evaluate the diversity of ways in which we creatively struggle to make sense of such experiences and express ourselves across a range of media.

Among the themes these projects explore are: • •

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the ‘significance of health’, illness and disease for individuals and communities the concept of the ‘well’ person; the preoccupation with health; the attitudes of the ‘well’ to the ‘ill’; perceptions of ‘impairment’ and disability; the challenges posed when confronted by illness and disease; the notion of being ‘cured’ how we perceive of and conduct ourselves through the experiences of health and illness ‘models’ of the body; the body in pain; biological and medical views of illness; the ambiguous relationship with ‘alternative’ medicine and therapies; the doctor-patient relationship; the ‘clinical gaze’ the impact of health, illness and disease on biology, economics, government, medicine, politics, social sciences; the potential influences of gender, ethnicity, and class; health care, service providers, and public policy the nature and role of ‘metaphors’ in expressing the experiences of health, illness and disease - for example, illness as ‘another country’; the role of narrative and narrative interpretation in making sense of the ‘journey’ from health through illness, diagnosis, and treatment; the importance of story telling; dealing with chronic and terminal illness the relationship between creative work and illness and disease: the work of artists, musicians, poets, writers. Illness and the literary imagination - studies of writers and literature which take health, disability, illness and disease as a central theme Dr Robert Fisher Inter-Disciplinary.Net http://www.inter-disciplinary.net

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Contents Introduction Bernie Warren

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Collective Depression: Its Nature, Causation and Alleviation William W. Bostock

1

A Study of Psychological Well-being, Job Satisfaction and Sources of Pressure of Medical Consultants and Post Graduate Students. Vijayalaxmi A. Aminabhavi and Ajitha Dindigal

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Evaluation of the Historical Recent Past: Humour as a Possible Collective Coping Strategy Judit Ujlaky

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The Medicalization of Emotions: Happiness and the Role of General Practice Louise Woodward and Ian Shaw

43

Nervios: Lessons from Cuba’s Oriente Traci Potterf

61

The Role of Negative Self-concept in Depression, Stress, and Anxiety of Married Women Banoudokht Najafianpour

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Hong Kong’s Female Sex Workers: Stress and Anxiety-related Consequences of the Intersection of Poverty, Gender, Dangerous Work Eleanor A. Holroyd, William C.W. Wong, Davina C. Ling, Ann Gray

93

We Aim To Pee: Unmasking the Secret Phobia and Reducing Performance Anxiety Alex P.W. Gardner

103

Asylum Seekers in Australia: Turning Repression and Stress into longterm Anxiety and Depression Harold A. Bilboe

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The Hospital Clown: A Cross Boundary Character Tom Doude van Troostwijk

137

Clown Language, Performance and Children’s Hospitals Ana Achcar

149

LaughterBoss – The Court Jester in Aged Care Dr. Peter Spitzer

165

“Nothing seems funny anymore”: Studying Burnout in Clown-Doctors Nicole Gervais, Bernie Warren and Peter Twohig

175

Expressing Sensibilities: Healing Functions of Humour in Palliative Care Ruth Anne Kinsman Dean 191 Collective Bibliography

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Index

229

Introduction Bernie Warren In 2004 Rob Fisher and I sat down in Oxford to “speak of many things.” Our conversations took place on a summer’s afternoon at a break between sessions at the 3RD INTERNATIONAL CONFERENCE ON MAKING SENSE OF HEALTH, ILLNESS AND DISEASE. One of the many things I wanted to discuss was the development of a themed conference, similar to HEALTH ILLNESS AND DISEASE THAT focused on HUMOUR AND HEALTH. As it so happened, Rob was planning a conference on MAKING SENSE OF STRESS ANXIETY & DEPRESSION which he envisioned taking place in May 2005 in Budapest. The more we talked the more we thought it would be worth offering the two conferences in parallel. So we sent out calls for papers for the two separate conferences. As we started receiving papers it became crystal clear that there was such a strong cross over of themes and ideas that it made more sense to amalgamate the two conferences into one. This was how MAKING SENSE OF STRESS HUMOUR AND HEALING came into being. The conference brought together a group of artists, academics and clinicians from all over the globe 1 to discuss not only the rapidly expanding and worrying increase in the effects of depression, stress and anxiety on the way people live and think today but also how the use of humour and laughter, may help alleviate these conditions and improve quality of life for everyone This book “SUFFERING THE SLINGS AND ARROWS OF OUTRAGEOUS FORTUNE 2: INTERNATIONAL PERSPECTIVES ON STRESS. LAUGHTER AND DEPRESSION” highlights topics covered at this inaugural inter-disciplinary conference held in Budapest in May 2005. The chapters provide a truly International and inter-disciplinary perspective on the subject. Contributors to this volume come not only from a wide variety of disciplines and backgrounds but also from many parts of the globe. They speak of universal truths and of site-specific concerns. They do not all speak with one voice and some of their points diverge one from the other but each sheds their own light on the topics, allowing readers to form a richer picture of the issues than might otherwise be possible. William Bostock (Australia) opens the book by discussing the notion of “collective depression”. In it he discusses how certain events 1

Australia, Brazil, Canada, Chile, Cyprus, France, Finland, Germany, Greece, Hong Kong, Hungary, The Netherlands, India, Iran, UK, USA. 2 The title of the book alludes to Hamlet’s famous “To be or not to be…” Soliloquy (William Shakespeare, Hamlet, Act 3 Scene 1).

ii

Introduction

____________________________________________________________ may trigger collective depression, how this form of depression may be considered to be contagious and how it may be contained or reversed. Vijayalaxmi Aminabhavi & Ajitha Dindigal (India) consider the relationship between Psychological Well Being, Job Satisfaction and Sources of Pressure on Hospital Consultants and Post Graduate Medical Students. They look at variables such as gender, marital status, professional status and sense of well-being. The conclusions gained from their study are of relevance to many beyond the field of medicine. Judit Ujlaky (Hungary) considers how humour may be used as a possible collective coping strategy especially during oppressive regimes. She makes suggestions as to how the joke may be used not only as a currency to bind people together but also to avert the collective depression that Bostock refers to earlier in this volume. Louise Woodward & Ian Shaw (UK) suggest that Depression as we understand it would not have been recognised fifty years ago. They cite recent reports that suggest that 1 in 4 people who attend General Practitioners surgeries in the UK have depression and then discuss whether emotional rather than clinical need is transforming the medical encounter with physicians. Traci Potterf (USA) reports on her work in Cuba. Her chapter looks at cultural factors that create what she refers to as nervios (a condition primarily associated with depression, stress and anxiety). She goes on to examine people’s perceptions of how political economic and socio-cultural factors combine to produce nervios and to influence their struggles to overcome it. Banoudokht Najafianpour (Iran) discusses the role of negative self-concept in depression, stress, and anxiety of married women in Iran. She describes a treatment program that includes individual & group therapy as well as group physical activities and “pleasant excursions” and in doing so gives a glimpse of some of the problems involved in delivering such a treatment program in a Muslim country. Eleanor Holroyd et al. (Hong Kong) discuss the occupational stress and anxiety-related concerns that affect Hong Kong's female sex workers. They go on to look at the connections among poverty, gender, and dangerous work. Alex Gardner (UK) discusses Avoidant Paruresis (also known as Shy Pee or Bashful Bladder), which affects 7% of the population of Westernised countries. The problem is so severe for some that they are unable to attend work or form lasting social relationships. His chapter explores some of the possible psychological factors contributing to this condition and discusses implications for treatment and Quality of Life in the context of interpersonal relationships and the living environment. Harold Bilboe (Australia) talks of the anxiety, stress and depression that affect asylum seekers who often face long periods of internment. His chapter explores the question of trauma and traumatisation during the

Bernie Warren iii ____________________________________________________________ detention process and raises the question whether the detention process is a form of psychological torture? Peter Spitzer (Australia) Ana Achcar (Brazil) and Tom Doude van Troostwijk (The Netherlands) all talk about different aspects of clown work in hospitals and healthcare facilities. Doude van Troostwijk considers the “hospital Clown” as another variant on the Trickster figure. Suggesting that the hospital clown is an individual who not is confined by the rules of the hospital and is thus able to break through the boundaries created by ‘red tape’ and classifications of illness. Achcar looks at the training of performers who wish to work as hospital clowns with children in Brazil. Echoing themes in Doude van Troostwijk’s work she considers the relationship between laughter and health; clown and child; reality and fun; and art and transformation. Spitzer discusses “The Laughter Boss” model where a staff member is trained to bring humour into a seniors’ facility. He suggests that The Laughter Boss”, who utilises performance skills to manifest the art of medicine at this difficult late life stage to make a positive psychosocial impact, can be seen as the reincarnation of the court jester in the new millennium. Nicole Gervais, Bernie Warren and Peter Twohig (Canada) look at the effects of clowning in hospitals and healthcare facilities on the clowns themselves. They describe factors that may create burnout among clown-doctors. They also detail methods and approaches used by individual clown-doctors and organisations in working to prevent and counteract ‘burnout.’ Finally Ruth Dean (Canada) looks at the use of humour in Palliative Care. She examines how humour helps to build relationships, contend with difficult circumstances, and communicate messages too painful to be spoken aloud. She contends that humour may serve healing functions and prove a powerful asset to therapeutic relationships.

Bernie Warren Ph.D. Professor, University of Windsor Canada January 2006

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Acknowledgements First I want to thank Rob Fisher who I respect immensely as a scholar and a visionary. His work to create opportunities for artists and academics to explore the boundaries and connections between and among ideas and then to engage in discourse with others of like mind cannot be too highly lauded! More than this I am proud to call him “friend”. I also want to thank Stephen Morris, who when Rob was laid low with unbearable pain and could not fly to Budapest, stepped into the breach to make sure that the conference did not go off the rails. I acknowledge without hesitation that this book would not have seen the light of day without Stephen’s involvement at the conference. For this and the conference’s success I owe a debt of gratitude to him. Above all I must thank my editorial assistant, Nicole Gervais. This book would not exist without her tireless efforts and technical skills. She handled almost all the correspondence with contributors and made sure that their chapters met the required format. She met regularly with me, worked hard to keep me on task, accepted (almost) all my last minute changes and made many fine suggestions that improved the final work. Again thank you!

Bernie Warren Ph.D. Professor, University of Windsor Canada January 2006

Collective Depression: Its Nature, Causation and Alleviation William W. Bostock Abstract Depression is a normal mental condition characterised by a sense of inadequacy, despondency, lack of vitality, pessimism and sadness. But depression can be a serious illness with the potential to become a world epidemic. Major depression is a condition that can cause an inability to function or even suicide but can remain undiagnosed. Collective depression can be related to national trauma, that is, a shock felt by a very high percentage of a population. Other causes of collective trauma are political assassinations, episodes of genocide, acts of war, economic depressions, technological disasters, natural disasters, and uncontrolled pandemics. All of these events can trigger collective depression, either in a direct way, or by a more insidious process of gradual accretion. As depression may be passed between individuals by contagion, treatment involves leadership, group development, social learning, collective insight, political changes, and even just the passing of time, though the healing process may never be complete. The function of leadership in alleviating collective depression is to correctly diagnose the causes of the depression, and then to demonstrate that situational factors can be changed. But bad leadership can also be the cause of collective depression through what has been called toxicity. As with individual depression, collective depression can have a positive or functional side, leading to growth of insight in a process that can later be recognised as heroic. The incremental modification of collective depression will inevitably lead to the gradual lifting of individual depressions by the mechanism of 'reverse contagion'. 1.

The Nature of Depression

Depression is a word that describes a normal and familiar mental condition of a sense of inadequacy, despondency, lack of vitality, pessimism and sadness.1 Depression can also be a serious illness: one afflicting each year 19 million Americans,2 or 8 percent of the British population,3 with a lifetime risk to 5-12 percent of men and 9-26 percent of women in Western countries.4 In French the word ennui (worry, anxiety) carries some of the meaning of the word depression in English, leaving dépression for more severe situations, so that depression in English tends to be a rather overworked term. Interestingly, dépression

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Collective Depression: Its Nature, Causation and Alleviation

____________________________________________________________ nerveuse is a nervous breakdown, a non-medical term meaning failure to cope psychologically with stress manifesting in incapacitating mental and emotional disturbance and frequently severe depression. The normal lowering of spirits in response to life's events used to be called reactive depression, and the depression with no apparent precipitant was formerly called endogenous depression.5 This distinction is now often replaced with a classification of (1) mild, moderate or severe (2) with or without biological features (3) with or without delusions or hallucinations (4) with or without manic episodes (bipolar/unipolar).6 Major depression is a very serious condition that can cause an inability to function or even suicide but can remain undiagnosed. Its aetiology is not fully known but could be (1) biochemical: there are excess 5-hydroxytryptamine (5-HT2) receptors in the frontal context of the brains taken from suicide victims7 (2) endocrinological: about 1/3 of depressed people do not have normal cortisol suppression in the dexamethasone test8 or (3) psychodynamic: often actuated by the death of someone close or other forms of profound loss and is therefore a product of grief.9 In the Freudian view, depression mirrors bereavement, but the loss can be an object and not simply a person.10 Another view is that learned helplessness, the hallmark of depression, results when punishment is received without being contingent upon the actions of the individual.10 Depression can also be related to illness, pain, prolonged fatigue, and lack of human contact: deep areas of causality possibly best understood by imaginative artists, especially literary people who often analyse it under the term melancholia. Many writers have also recognised that depression has a positive function in enriching insight, inner resourcefulness, spirituality and resilience. Depression is often called the ‘common cold’ of mental illness,11 and is generally classified under the class of Mood Disorders. However, its major complication leading to suicide causes it to be among the leading causes of death.12 The growing incidence of suicide among young people in many different countries indicates the extent of the problem. In addition, depression is generally linked to other major illnesses particularly but not only afflicting young people such as substance abuse, HIV/AIDS and other illnesses caused by lowered immunity. The World Health Organization has recognised the significance of depression, noting that mood disorders (of which depression is a major part) are estimated to affect some 340 million people, and that in the United States of America alone, the yearly cost of depression is estimated at US$44 billion, equal to the total cost of all cardiovascular diseases.13 Suicide and violence to others including homicide are closely related. The WHO reports that violence in all its forms has increased dramatically worldwide in recent decades. During 1993, at least 4 million deaths resulted from unintentional or intentional injury, including 300 000

William Bostock

3

murders. Of the violent deaths, some 3 million were in the developing world. In many countries, homicide and suicide account for 20%-40% of deaths in males aged 15-34 and in half the countries of Latin America and the Caribbean, homicide is the second leading cause of death in people aged 15-24. It is more frequent among men and increases in direct relationship with age, and is closely associated with depression, personality disorders, substance abuse and schizophrenia.14 It should be noted, however, that sufferers of specific mental illnesses generally have no greater proclivity towards violent crime than other members of a population.15 Depression among individuals is thus a vast worldwide problem, receiving the attention of governments in Australia, Canada, the United Kingdom, and many other countries. Depression can also affect whole sectors or strata of society, or specific groups, or communities and nations and even whole continents, and can be so widespread and generalised that the term collective depression can be used to describe the situation. It can afflict specific sections of a population, such as was the case with the women of Talibanruled Afghanistan.16 A specific event, such as the unexpected death of a revered public figure, or an unprovoked attack, can be the cause of an episode of collective depression. The assassination of political leaders or the accidental death of a figure highly symbolic among young people, as Princess Diana was, have been noted as events profoundly upsetting at the collective level as well as to individuals.17 The 9/11 attack on the World Trade Center and the Pentagon provoked a severe episode of collective depression.18 Other causes of collective trauma are economic depressions, and technological disasters and the introduction of new technology. Collective depression can be triggered either in a direct way, or by a more insidious process of gradual accretion. The theologian and psychologist José Maria Vigil has investigated the psychological well-being of the Latin American continent and diagnosed a state of collective depression, that is, as having actually the same symptomatology as for individual depression: disappointment, loss of self esteem, self accusation, demobilisation, disorientation, depoliticisation, escape into spiritualism, loss of memory, withdrawal and psychosomatic problems.19 Michel Rocard, a former Prime Minister of France, has written of a ‘dépression nerveuse collective’ (collective nervous breakdown), presently confronting France, Europe and the world.20 It is possible in a similar way, to assess the condition of a large proportion of young people in Western countries as being one of collective depression. The World Health Organization’s Global Burden of Diseases project estimated that of the ten leading causes of disability worldwide in 1990, measured in years lived with disability, five were psychiatric conditions, while in the developed regions, unipolar major depression was second only to ischaemic heart disease as a cause of disability. In the

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Collective Depression: Its Nature, Causation and Alleviation

____________________________________________________________ developed regions, alcohol use is the leading cause of male disability and in the developing regions it is the fourth largest cause of male disability.21 As in other countries, mental health is a major problem in China. Using 1982 data, there were over 15 million patients with mental health problems.22 Among the world's indigenous peoples, there is a major widespread condition of depression, alcoholism and suicide to a large but still unknown degree.23 In Australia, as in many other countries, youth suicide has increased to the extent that it has also been described as an epidemic. In 1950, the (age-adjusted) suicide rate for males aged 15-24 was 6.9 per 100 000 and, in 1995, 24.8 per 100 000; among females in this age group, the suicide rate in 1950 was 2.2 and, in 1995, 6.2. When suicide follows homicide, then the tragedy of the outcome can become compounded.24 Collective depression presupposes the concept of a collective mind, which causes a philosophical problem in discussing collective depression. Although accepted by Plato and Aristotle, who wrote of the body politic, then developed in nineteenth century Europe by Le Bon, Durkheim and then Freud as collective consciousness, Jung as the collective unconsciousness, and collective memory by Halbwachs, it has been contested by those who argue for a theory that sees group unanimity as an illusion created by common action based on prevailing norms. The psychologist Reber defines group mind as a “…hypothesized, collective, transcendent spirit or consciousness which was assumed by some to characterize a group or society.”25 The methodological difficulty of assessing any concept of group mind has meant that it has been ignored by mainstream English-language discussion, with the result that there is very little research currently being undertaken (Varvoglis, 1997: 1). The fact that Marx proposed a concept of group mind in the form of class consciousness also have played a part in the Anglo-American distaste for this avenue of enquiry. Indeed, in conference discussion, this very point was made: that participant found it impossible to accept the concept of a group mind. Some medical writers address this problem by leaving open the question of collective mental states: for example, Cawte states that a sick society is simply one with a high amount of psychiatric illness.27 As a consequence, it is possible, without accepting the concept of a group mind, to state that collective depression can exist when a large proportion of the members of a society are depressed, that is, when they are displaying signs of inadequacy, despondency, lack of vitality, pessimism, sadness and dependency upon substance abuse, in other words, as already noted, the same symptomatology as individual depression. As already noted, many governments have seen fit to address the problem of widespread depression: for example, the Australian Government has created a national program to treat depression, as initiated

William Bostock

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by former premier of the State of Victoria, Mr Jeff Kennett, and this has provoked discussion of whether the condition should be treated biologically or socially, but left open the question of its collective nature.28 2.

The Causes of Depression

Psychological factors are recognised as being very important as causes of depression. For example, depression is often actuated by the illness or death of someone close or other forms of profound loss including loss of hope for the future or other form of grief.29 Individual depression is thus characterised by a loss of personal hopefulness which is now becoming recognised as an important part of the mind-body relationship,30 and this applies equally to group depression. Another variant of this view is that depression is caused by feelings of learned helplessness, which results when punishment is received without being contingent upon the actions of the individual.31 Learned helplessness could be considered as similar to a loss of control over one's life, even in, or particularly in a situation of hardship and mundanity. And moreover, can afflict whole populations. When a triggering event has occurred, the cause of collective depression is perfectly obvious and understood by all. But there is also a more generalised and non-specific state of collective depression where causality is not so clear. For example, depression among young people in affluent Western countries that many have recognised may be a product of tension in global culture: on the positive side of this particular stage of cultural development is the promise of infinite lifestyle possibilities, choice, freedom and consumer goods, while on the negative side, which is more likely to correspond to reality, is poverty, disease, deprivation and the loss of hope, a mind-set to which young people are particularly susceptible. As has been stated by one commentator, …(this) situation may also reflect a growing failure of modern Western culture to provide an adequate framework of hope, moral values, and a sense of belonging and meaning in our lives, so weakening social cohesion and personal resilience…. In investing so much meaning in the individual "self", we have left it dangerously exposed and isolated, because we have weakened the enduring personal, social and spiritual relationships that give deeper meaning and purpose to our lives.32 Thus the deep inner void created in young people by a marketorientated society can be linked to a form of collective depression. This has been called a loss of sense of coherence by Antonovsky.33

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Collective Depression: Its Nature, Causation and Alleviation

____________________________________________________________ Are depression and suicide communicable diseases? Researchers in the nineteenth century and even earlier have long been aware that suicide can occur in a series or as a mass event.34 It would seem comprehensible that the mood of depression can also be passed between individuals by contagion, but does research give any confirmation? Forsyth reviewed the literature and concluded “…the bridge between social psychology and mental health can still not be traversed.”35 Thus, the contagion theory must remain conjectural at the present stage. Economic depression is a useful analogue for understanding collective (mental) depression. Economic depression is defined as a severe and prolonged recession, where income, output, and employment fall, sales and new projects decline, investment is reduced, interest rates fall, and deflation may occur, resulting in widespread bankruptcy and mass unemployment. It is a collective phenomenon, passed by contagion, with each business closure bringing others in its train by negative multiplier effect. The contagion with emotions about future economic behaviour can also occur in other domains of behaviour, and an epidemic of suicide is often a consequence of economic collapse. Other collective mental states besides depression have been proposed, giving confirmation to the concept. For example, Kiev hypothesised a collective anxiety neurosis.36 Collective fear has been isolated as a causal factor in genocide and collective paranoia in ethnic cleansing.37 Clearly there is evidence that depression, or any other mental state, can be passed between individuals by contagion or sociogenesis but research has yet to fully explain how this occurs. However, there are many historical examples of successful intervention by practitioners of many arts and sciences operating at an intuitive or inspirational level. 3.

Alleviating Collective Depression

Individual depression can be successfully treated by a range of therapies: pharmacological, neurological, psychological, and occupational. Spiritual, artistic and humour-based approaches have also been highly successful. But while individual depression can be successfully treated by this range of therapies, when it is affecting a large number of people collectively, it needs an additional approach. Collective depression can be treated through group dynamics. Forsyth suggested some areas of enquiry, such as the causal power of the group to change individuals when they become part of a group. Some of the group processes that require research are leadership, group development, social learning, self-insight, social influence and social provisions,38 as noted by Forsyth. Vigil also notes, as we have seen, that although the Latin American continent has a state of collective depression, there are individuals standing outside this mental state and therefore are in a position to assist in its removal. Vigil refers

William Bostock

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those who remain firm, and impervious to dismay and depression “...our Latin American prophets, anonymous, hidden in the barrios, in the countryside, in the popular, feminist, indigenous, black, and labour movements ...” 39 As with individual depression, positive practical action to neutralize fear seems to be a fundamental step. Nehru wrote this of Gandhi, The essence of his teaching was fearlessness and truth and action allied to these…. So, suddenly as it were, that black pall of fear was lifted from the people's shoulders, not wholly, of course, but to an amazing degree…It was a psychological change, almost as if an expert in psychoanalytic method had probed deep into the patient's past, found out the origins of his complexes, exposed them to his view, and thus rid him of that burden.40 As well as dealing with fear, there are numerous other activities, no matter how seemingly small in comparison with the magnitude of the task, which can lead to a lifting of the condition, as shown with the work of some members of a Peace Institute in a village in war torn Georgia.41 Generally, deeply entrenched situations leading to depression on a large scale require the efforts of major personalities, and the contributions of historically significant figures to the alleviation of collective depression are many, (not forgetting that historical figures can also be the cause of major collective depression). However, the case of South Africa provides one outstanding example of how leadership has played a determining role in bringing about changes of previously incomprehensible magnitude in state organization, and thus alleviating, but not eliminating, collective depression. Writing of the Apartheid policy in South Africa (1948-1994), one observer described it thus “…(a)s an exercise in ambitious and brutal social engineering, it had few parallels in human history.”42 Yet the system was ended, without violence and with astonishing speed, by the leadership of three major interacting players. It is possible to interpret South African policy under minority rule as an attempt to influence collective mental state by division into a multiplicity of separate collective mental states, with an overall aim of securing and enhancing the future of one group at the expense of the others, to a major or minor degree. For blacks it sought to create a collective mental state of insecurity, depression, dampened sense of realism, exclusion and habituation to violence. For South Africans of British background it aimed to create some feelings of insecurity, depression, and through the hint of the likelihood of violence it offered the possibility of inclusion in the Afrikaner collective as a shelter. Among

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Collective Depression: Its Nature, Causation and Alleviation

____________________________________________________________ Afrikaners, it sought to create a mental state of a secure future, and a mood of elation through the delusion of a God-given destiny based on an unrealistic belief in the sustainable viability of a policy of exclusion of Africans, underlain with a habituation to a putative ever-present threat of violence. An explanation of the highly complex political process that has been called ‘surrender without defeat’ must include the role of the major players: de Klerk, Mandela and Tutu. De Klerk's role, after what has been described as his “remarkable change of heart,”43 was one of bringing to the Afrikaner mental state some acceptance of the reality of an untenable situation, though he was not entirely successful in this. It is reported that in a meeting one of his ministers angrily hurled at him the words “What have you done?! You have given South Africa away!!”44 Mandela's contribution was to see the new South Africa as a larger collective through the inclusion of all groups in the new collective mental state where there would be a place and a role for even his former persecutors. It has been said of leadership that “…the fundamental process is a more elusive one; it is, in large part, to make conscious what lies unconscious among followers.”45 On this last point, Mandela was been highly sensitive to the need to embrace Afrikaners and their language and parts of their culture in the new Rainbow Nation. The third major player was Archbishop Tutu whose promotion of ubuntu, a traditional African communal practice of common humanity,46as embodied in the proposed and now realised Truth and Reconciliation Commission, provided a mechanism for the grief work necessary before the possibility of inclusion in the new collective mental state. The function of leadership in treating collective depression is thus to stand apart from the group, assess the obvious causes of the depression, and then to demonstrate that the situational factors can be changed, starting with small symbolic ways, if only with those few that are possible. But it must be noted that leadership with evil intent can also be the cause of heightened collective depression. Hirschhorn confirms this proposition with the conclusion that poor leadership can have “toxic effects” on organisational motivation,47 and, of course, the toxicity is cumulative. As with individual depression, positive practical actions, no matter how seemingly small in comparison with the magnitude of the task, can contribute to a lifting of the condition, as shown with many small scale actions and projects, in a similarly cumulative process. This linking mechanism could be called “positive or reverse contagion”, while attitudinal changes, including the use of humour, is another rich field of collective therapeutic action.

William Bostock 4.

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Conclusion

Collective depression is a highly undesirable but very widespread condition, easily recognisable by its effects, even if its precise philosophical status may continue to be disputed. Mostly it is treated with symptom-relieving practices and strategies which may help in short-term survival but which do not provide a long-term solution. Lasting resolution requires removal of the causes of collective depression such as, for example, the institutionalised system of discrimination which existed in South Africa, a hugely depression-inducing situation. In this case, the solution was through transforming leadership which enabled a removal of the sense of fear, the basis of collective depression. As with individual depression, collective depression can be treated with the therapeutic effect of small positive practical steps leading to the lifting of the sense of hopelessness. The incremental modification of collective depression will inevitably lead to the gradual lifting of individual depressions by the mechanism of ‘reverse contagion’. Major collective depression requires changes to the situational causality, such as the ending of war, famine or institutionalised discrimination. Along with its related conditions of global injustice, insecurity and resource depletion, it is a major challenge of the twenty first century.

Notes 1

2

3

4

5

6 7 8 9

D.J. Lincoln, “Depression” Perspectives, A Mental Health Magazine 3 (2000). (26 May 2000). Depression.com, “Types of Depression,” 2000, (22 August 2000). . J.A.B Collier, J.M. Longmore, and J.H. Harvey, Oxford Handbook of Clinical Specialities, Third Edition (Oxford, New York, Tokyo: Oxford University Press, 1991), 336. B.K Puri, P.J.Laking and I.H. Treasaden, Textbook of Psychiatry. (Edinburgh, London, New York, Philadelphia, Sydney, St Louis, Toronto: Churchill Livingstone, 1996), 161. A.S. Reber, The Penguin Dictionary of Psychology, Second Edition (London, New York, Ringwood, Toronto, Auckland: Penguin Books, 1995), 198. Collier et al., 338. Ibid., 336. Ibid., 336. Robin A Haig, The Anatomy of Grief, Biopsychosocial and Therapeutic Perspectives (Springfield: Charles Thomas, 1990), 7-11.

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Collective Depression: Its Nature, Causation and Alleviation

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Collier et al., 336. Mental Health Info & Links, Coping with Depression 2001, (March 3, 2001). http://www.gtonline.net/community/mindinfo/depression.htm>. 12 Denis Leigh, C.M.B. Pare and John Marks, A Concise Encyclopedia of Psychiatry. (Lancaster: MTP, 1977), 341 – 342. 13 World Health Organization, The World Health Report (March 3, 2001). 14 Ibid 15 T Siegfried, and S Goetinck, “Association Between Violence, Mental Illness Disputed.” Dallas Morning News, 1996, (March 3, 2001). . 16 Action Central, Petition #1, Afghanistan Women, 2001, (May 30, 2001). . 17 Lincoln. 2 18 MedicineNet.com, “Stress, Depression and Drug Abuse” Fallout of September 11, (16 March, 2005). 19 Jose Marie Vigil, 'The Present State of Latin America's Psychological Well-Being'. Tlahui-Politic, 2/11, (2). (30 August, 2000). 20 Michel Rocard, ‘La dépression nerveuse collective.’ 2000, (30 August, 2000). . 21 WHO, 2-3 22 Ji Jianlin, “Mental Health Services in Today's China”, Updates on Global Mental and Social Health, Newsletter of the World Mental Health Project, 3, 1, June 1999, (July 17, 2002). . 23 Alex Cohen, “Mental Health Issues Among Indigenous Peoples of the World”, Updates on Global Mental and Social Health, Newsletter of the World Mental Health Project, 3, 1, June 1999, (17 July, 2002). http://www.hms.harvard.edu/dsm/wmhp/updates/news0301/mhip030 1.htm>. 24 Richard Eckersley, “Psychosocial disorders in young people: on the agenda but not on the mend”. EMJA. (E Medical Journal of Australia), 1997 (30 May 2001). 25 . 26 Reber, 323. 27 M.P. Varvoglis, “Conceptual Frameworks for the study of transpersonal consciousness”. World Futures, 48, (January 1997): 105-114. 11

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J.E. Cawte, “A Sick Society,” in The Psychology of Aboriginal Australians ed. G.E. Kearney, P.R. de Lacey, and G.R Davidson (Sydney, New York, London, Toronto: J. Wiley and Sons, 1973), 365-379. 29 S. Busch, “Symptom of a Social Affliction,” The Australian (newspaper), March 15, 2000 (30 August, 2000). . 30 Haig, 7-11. 31 K.P. Nunn, “Personal hopefulness: A conceptual review of the relevance of the perceived future to psychiatry,” British Journal of Medical Psychology, 69, (1996): 227-245. 32 Collier et al., 336. 33 Eckersley, 1 34 A. Antonovsky, Unravelling the Mystery of Health: How People Manage Stress and Stay Well. (San Francisco: Jossey-Bass, 1987). 35 Ian Robertson, Sociology, Third Edition (New York: Worth, 1987), 4445. 36 D.R. Forsyth, “Interfacing Social and Clinical Approaches to Mental Health”. Virginia Commonwealth University, Grand Rounds Presentation, February 9, 1996 (30 August 2000). 37 . 38 A Kiev, “Psychiatric Disorders in Minority Groups”, in Psychology and Race, ed. P Watson (Chicago: Aldine, 1973), 416-431. 39 Danilo Kis, “On Nationalism”. Performing Arts Journal, 53, 18.2 (1996): 13-16. 40 Forsyth, 5. 41 Vigil, 3. 42 J. Nehru, “The Discovery of India,” in Gandhi, The Traditional Roots of Charisma, eds. S.H. Rudolph and L.I. Rudolph, First ed. (Chicago: University of Chicago Press, 1967), 6. 43 M. Rueffler, “Healing a Collective”. Association for the Advancement of Psychosynthesis, 2000, (30 August 2000). . 44 D. McLean, “Neocolonizing the Mind? Emergent trends in language policy for South African education,” International Journal of the Sociology of Language, 136 (1999): 7-26. 45 D.A. Lake, and D. Rothchild, “Containing Fear: the origins and management of ethnic conflict”, International Security, 21(2) (1996): 35. 46 H. Giliomee, “Surrender Without Defeat: Afrikaners and the South African ‘Miracle’”, Daedalus, 126, 2, (Spring) (1997): 113-134. 47 J.M. Burns, Leadership (New York: Harper and Row, 1978), 40.

12

Collective Depression: Its Nature, Causation and Alleviation

____________________________________________________________

Author William Walter Bostock, Ph.D., Senior Lecturer in Government, School of Government, University of Tasmania, GPO Box 252-22, Hobart, Tas., Australia 7001

A Study of Psychological Well-being, Job Satisfaction and Sources of Pressure of Medical Consultants and Post Graduate Students. Vijayalaxmi A. Aminabhavi and Ajitha Dindigal Abstract The study was conducted to assess psychological well-being, job satisfaction and sources of pressure in consultants and post graduate medical students in a government medical college of southern India. A total of 110 doctors were randomly selected. Psychological well-being, job satisfaction and sources of pressure scales were administered. The difference between the two groups was found to be significantly different in the total scores of psychological well-being, job satisfaction and sources of pressure. The consultants had significantly higher psychological well-being and sources of pressure when compared to post graduate students. Whereas, post graduate students showed significantly higher job satisfaction when compared to consultants. The analysis based on demographic factors revealed that female doctors, married doctors, doctors not having health problems and those practicing stress coping strategies had significantly higher psychological well-being when compared to their respective counter parts. Male doctors, married doctors and doctors not having health problems had significantly higher job satisfaction when compared to their counter parts. It can be concluded that though consultants had significantly higher sources of pressure, they had significantly high psychological well-being too. PGs had significantly higher job satisfaction. Female doctors reported significantly higher psychological well-being and job satisfaction than male doctors, but no difference in sources of pressure. Married status was associated with significantly high psychological well-being and job satisfaction, however it did not have effect on stress coping strategies. Healthy doctors had significantly higher psychological well-being and job satisfaction. But they did not differ with their counterparts in terms of their stress coping. 1.

Introduction

Medical professionals must endure enormous amounts of work related stress. There are experiences that are intrinsic and unique to health professions and medical practitioners in particular. These include the experience of dealing with death and dying patient, and the whole panoply of human experience. Doctors often have responsibility for the relief of suffering in a setting where expectations of others far exceed even the greatest doctor’s ability1. Medical students are also exposed to numerous

14 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ stressors. Long hours of studying, emotionally taxing experiences, the need to survive and excel in high stress environments, meeting the course requirements, interpersonal problems and lack of social and family life are some of them. A general health survey found that over 50% of medical students reported high stress2. The prevalence of emotional disturbance due to stress in British medical students is reported as 31.2%. A similar number was reported for American medical students also3. Prevalence of any common mental disorders in doctors is as high as 28% compared with 15% in general population and 1 in 15 doctors are believed to have a substance use disorder4. Suicide rates are highest in anaesthetists, general practitioners and psychiatrists and women doctors are 3-4 times more likely to commit suicide5. Indeed, the profession is so stricken with ‘wounded healers’ that the care of physicians has become a large field of work6. Positive health and well-being of doctors working in high stress environments have not attracted the attention of the researchers. However, a lot of studies on their physical and mental ill being have been reported. Some studies have found that 46-60% doctors felt that work had affected their physical health and high levels of self reported occupational stress is predictive of greater ambulatory blood pressure7, 8. Due to increased stress, doctors and nurses with hypertension are more vulnerable to angina pectoris, myocardial infarction, and cerebrovascular insult9. Population survey in Britain revealed that trend over the last 2 centuries show that doctors have higher risk for cirrhosis, accidents and poisoning10. The rates of suicide in European and North American doctors compared with general population is between 1.1-3.4 times more in males and 2.5-5.7 times more in females11. Most recent studies show some astonishing findings with regard to mental health of doctors. A major study reported that 61% suffered moderate to severe depersonalization, 50% suffered substance use disorder, 31% suffered mild to moderate severe depression and 13% were on treatment for depression12. Equal prevalence of psychiatric morbidity has been reported both in consultants and post graduates 13. British Medical Association reported 7% of doctors addicted to alcohol and some other chemical substances14. In a comprehensive study it was found that 54% to be anxious, 25% having borderline depression and 29% clinically depressed15. Significantly high levels of perceived stress were reported by several authors recently. The figures range from 47% - 48% to 55% 16, 17, 18 . The most frequently reported reason for stress include stressors at work place, work itself, family and personal variables like personality (perfectionist attitude, self critical), coping skills, etc. Workshops held on reasons for unhappiness in doctors found that poor pay, increased work load, reduction in autonomy, more accountability, consumer model,

Aminabhavi, Dindigal

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___________________________________________________________ unreasonable expectations of patients, emotionally demanding job, poor mutual support, nature of selection, training, and socialization, taking personal responsibility and working in resource constrained environment19. Changing demands, isolation, disillusionment, and poor relationship with other doctors was also reported20. The other important stressors included, dealing with friends and relatives as patients, lack of emotional support at home, being unorganized, fast consultation rates and allowing inappropriate telephone or other interruption, lack of time, lack of feedback on effectiveness, day-to-day bureaucracy, and lack of administrative support, lack of consultation about organizational changes and inadequate computer support systems and training, government interference in their work, overstretched, effect of hours on personal life, leisure time activities, compromising on standards when resources were short, lack of recognition of one’s work, too much responsibilities at times, keeping up to date with knowledge and making the right decision alone.21, 22, 23, 24 In spite of vast medical literature giving indication of stressed out doctors, certain beliefs still exist in the society and medical professionals. The 3 great myths that exist are; 1. Doctors don’t get stressed; 2. Doctors don’t get sick; and 3. Even if they did, their colleagues would quickly treat them for free25. Doctors are believed to be “men of steel” and are immune to stress and disease. The society expects them to have high levels of tolerance, and well-being. The curers are believed to lead a healthy life style themselves, protect society’s health and contribute significantly to society’s health maintenance. To the contrary, they are human beings first and doctors next, hence they are equally susceptible to stress and disease. The present study aims to investigate levels of psychological well-being, job satisfaction and sources of pressure in them. The Indian context is unique due to the fact that the total population is to the excess of 1 billion, has limited resources, limited utilization of health care services by population, existence of alternative medical systems (e.g. Ayurveda, Homeopathy, etc.). Hence the doctors in India are assumed to be experiencing high levels of stress and low levels of psychological wellbeing. 2.

Method

A randomly selected sample of 110 doctors (consultants=55, post graduates=55) were chosen from government medical college, Karnatak Institute of Medical Sciences, Hubli, Karnataka, India. These 110 doctors belonged to all the specialties. Consultants working as lecturers, assistant professors, associate professors and professors or head of the departments were included in the study. Similarly post graduates from PG diploma class as well as master’s degree class were included in

16 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ the study. Out of 150 questionnaires distributed only 115 were returned; i.e. the response rate was 76%. Finally only 110 were included in the study as 5 were incomplete. The chosen subjects were asked to fill up an 11-item socio-demographic data sheet and 3 questionnaires which assess psychological well-being, job satisfaction and sources of pressure. Psychological well-being was assessed with the help of psychological well-being inventory. It is a 28 item self-rated inventory. It measures well-being in terms of meaninglessness, somatic symptoms, self esteem, positive affect, daily activities, life satisfaction, suicidal ideation, personal control, social support, tension, wellness, general efficiency, and satisfaction as experienced by the individual. This instrument has been standardized on 230 normal adults. It has internal consistency coefficient of 0.84 and split half coefficient of 0.91. Test stability studied over 3 months yielded a coefficient of 0.71. It also has high correlation with other well known well-being instruments such as subjective well-being questionnaire of Nag pal and Sell (correlation=0.62) and general wellbeing questionnaire by Verma and Verma (correlation=0.48)26. Job satisfaction and sources of pressure was assessed using Occupational Stress Indicator27. The indicator has 6 sub-scales measuring how one feels about his/her job, his/her current state of health, the way one behaves generally, how one interprets the events around one’s self, sources of pressure in one’s job and how one copes with stress. For the present study 2 sub-scales 1. How one feels about one’s job and 2. Sources of pressure were utilized. The subscale measuring job satisfaction has 22 items while the scale measuring sources of pressure has 61 items. In both the scales the subject is asked to choose ranks from1 to 6. In job satisfaction scale ‘1’ represents “very much dissatisfaction” where as ‘6’ represents “very much satisfaction”. Similarly, sources of pressure are also measured with the help of ranks 1 to 6. ‘1’ represents “very definitely not a source” and ‘6’ represents “very definitely a source”. Hence the lesser score on job satisfaction means lower satisfaction and higher score on sources of pressure means high stress or sources of pressure. 3.

Procedure

The consultants and postgraduate students chosen from all the specialties were administered all the four tools. Though the questionnaires had self-explanatory questions, clarifications were made whenever required. All of them were contacted in their respective departments and the questionnaires were handed over. They were given 2-3 days time to complete and return them. The investigator had to do this because of their busy schedule. In spite of reminding the subjects personally and over the phone, the return rate was only 76%.

Aminabhavi, Dindigal

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___________________________________________________________ 4.

Analyses

The obtained responses were then scored as per the instructions by the respective authors. These scores were then converted to ‘t’ scores for further analyses. Then means and standard deviations were calculated for all the dimensions and the totals of each variable. Based on these, further analyses like ‘t’ test to compare and determine the significance of difference between the two groups and also ANOVA was done to compare surgical, clinical and para-clinical groups. ANOVA can be used to test the significance of differences among three or more than three groups. 5.

Results

Table 1: Means, S.Ds, and ‘t’ Values for Different Dimensional Scores of Psychological well-being of Medical Consultants and Postgraduates. (N=55 in each group) Psychological wellbeing Dimensions

Groups

Mean

SD

‘t’ Value

Meaninglessness

Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants PG Consultants

51.40 49.43 49.00 50.29 48.05 45.03 51.20 48.54 50.54 50.81 51.41 47.43 51.09 49.34 51.94 48.01 49.30 50.47 52.12 47.80 50.00 49.45 50.50

9.40 11.30 10.46 9.62 9.62 9.36 8.90 11.92 9.50 9.02 9.00 10.12 9.19 11.28 10.03 9.83 10.86 8.74 9.10 10.81 9.70 10.92 9.90

2.10*

Somatic Symptoms Self Esteem Positive Affect Daily Activities Life Satisfaction Suicidal Ideas Personal Control Social Support Tension Wellness General Efficiency

-1.13 3.32** 2.82** -0.03 4.33*** 1.78 2.97** -1.23 4.49*** 0.55 0.93

18 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ Satisfaction Total Well-being

PG Consultants PG Consultants PG

49.58 50.83 48.54 52.72 49.22

10.63 9.80 9.81 10.24 10.40

2.43* 4.01***

* P<0.05; Significant ** P<0.01; Highly Significant *** P<0.001; Very Highly Significant An observation of Table-1 shows that difference between consultants and postgraduates is significantly very high in the dimensions of Psychological well-being such as life satisfaction and tension as well as for the overall psychological well-being. The difference between them is significantly high in the dimensions such as self-esteem, positive affect and personal control. Further the difference between the two groups is significant in the dimensions such as meaninglessness and satisfaction. Lastly the two groups do not differ significantly from each other in the remaining dimensions such as somatic symptoms, daily activities, social support, wellness and general efficiency. Thus it can be inferred that consultants have significantly higher subjective well being due to the dimensions like meaninglessness, self esteem, positive affect, life satisfaction personal control, tension, and satisfaction when compared to PGs. Even with regard to overall psychological well-being the consultants have higher score than PGs. Table 2: Means, SDs, and ‘t’ Values for Different Dimensional Scores of Job satisfaction of Medical Consultants and Postgraduates. (N=55 in each group) Job satisfaction Dimensions Satisfaction with Achievement, Value and Growth Satisfaction with job itself Satisfaction with Organisational Design and Structure Satisfaction with Organisational Process Satisfaction with Personal

Groups

Mean

SD

‘t’ Value -2.93**

Consultants PG

48.50 49.81

13.34 11.11

Consultants PG Consultants PG

49.90 50.27 47.36 48.61

8.80 10.62 10.89 8.15

1.02

Consultants PG

51.54 50.36

15.27 15.78

1.66

Consultants PG

53.81 52.00

6.54 10.00

3.62**

-3.28**

Aminabhavi, Dindigal

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___________________________________________________________ Relationships Total Job satisfaction

Consultants PG ** P<0.01; Highly Significant.

49.90 51.45

11.70 8.90

-2.97**

The above table shows that consultants and postgraduates differ significantly high in some of the dimensions of job satisfaction such as satisfaction with achievement, value and growth, satisfaction with organizational design and structure and satisfaction with personal relationships as well as for the overall job satisfaction. Both the groups do not differ significantly in the dimensions like satisfaction with job itself and satisfaction with organizational process. In other words it can be stated that PGs have significantly higher satisfaction with achievement, value and growth, satisfaction with organizational design and structure and over all job satisfaction when compared to consultants. Where as consultants have significantly higher satisfaction with personal relationships than PGs. Table 3: Means, SDs, and ‘t’ Values for Different Dimensional Scores of Sources of pressure of Medical Consultants and Postgraduates. (N=55 in each group) Sources of pressure Factors intrinsic to Job

Groups Consultants PG The Managerial Role Consultants PG Relationship with Consultants other People PG Career and Consultants Achievement PG Organisational Consultants structure and Climate PG Home / Work interface Consultants PG Total Sources of Consultants pressure PG ** P<0.01; Highly Significant *** P<0.001; Very Highly Significant

Mean 48.01 50.27 49.18 51.60 48.50 46.27 50.27 47.63 45.36 49.81 49.83 48.30 48.82 50.81

SD 9.64 10.10 9.23 11.58 9.77 10.00 7.65 10.00 9.64 9.63 9.86 10.53 9.50 10.06

‘t’ Value -4.93*** -4.40*** 4.95*** 5.91*** -13.90*** 3.65*** -4.52***

A perusal of Table-3 reveals that the difference between the two groups is significantly very high in almost all the dimensions of sources of pressure such as factors intrinsic to job, the managerial role, relationship

20 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ with other people, career and achievement and organizational structure and climate as well as the overall scores. It is significantly high in the dimension - home/work interface. It can be inferred from the above facts that PGs are having significantly higher stress due to factors intrinsic to job, managerial role and organizational structure and climate as well as in over all scores of pressure compared to the consultants. Where as the consultants have significantly higher stress due to relationship with other people, career and achievement and home-work interface factors when compared to PGs. Table 4: Means, SDs, and ‘t’ Values of Psychological well-being of Medical Professionals in Relation to their Gender, Marital Status, Health Problems, and Coping Strategies. Variable Gender

N 26 26 70 40 23

Mean 52.66 49.07 51.00 46.75 51.40

SD 16.40 10.70 10.29 10.58 8.10

23

48.17

10.10

71

50.78

10.10

Not 39 48.38 Utilising *** P<0.001; Very Highly Significant.

11.72

Marital Status Health Status

Coping Strategies

Groups Female Male Married Unmarried Not having health problems Having health problems Utilising

‘t’ Value 6.59*** 11.33*** 4.19***

6.27***

An observation of the Table-4 reveals that gender, marital status, health problems and coping strategies of medical professionals have very highly significant influence on their Psychological well-being. More specifically, female doctors are found to have significantly higher psychological well-being compared to their male counterparts. Married medical professionals have shown significantly higher well-being than unmarried medical professionals. Similarly medical professionals without health problems have shown significantly higher psychological well-being than those with health problems. Lastly it can also be noted that medical professionals who are practicing some form of stress coping strategies are found to have significantly higher psychological well-being than those who are not practicing.

Aminabhavi, Dindigal

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___________________________________________________________ Thus it can be stated that being female, staying married, absence of health problems and utilization of coping strategies are significant predictive of higher Psychological well-being. Table 5: Means, SDs, and ‘t’ Values of Job satisfaction of Medical Professionals in Relation to their Gender, Marital Status, Health Problems, and Coping Strategies. Variable Gender

Groups N Female 26 Male 26 Marital Married 70 Status Unmarried 40 Health Not Having 23 Status Health Problems Having Health 23 Problems Coping Utilising 71 Strategies Not Utilising 39 * P<0.05; Significant. ** P<0.001; Very Highly Significant.

Mean 49.00 51.20 50.70 48.00 52.60

SD 17.10 11.78 3.00 13.00 9.80

43.78

12.80

50.70 51.20

11.19 11.00

‘t’ Value -2.5* 4.82*** 7.11***

-1.21

Table 5 reveals that the factors such as gender, marital status and health status have significant influence on the job satisfaction of medical professionals. In other words, male doctors experience significantly higher job satisfaction than the female doctors. Married medical professionals have reported significantly higher job satisfaction than unmarried professionals and medical professionals without health problems have shown significantly higher job satisfaction than their counterparts. Therefore, it can be stated that being male, being married and the absence of health problems are associated with higher job satisfaction. Table 6: Means, SDs, and ‘t’ Values for Sources of pressure of Medical Professionals in Relation to their Gender, Marital Status, Health Problems, and Coping Strategies. Variable

Groups

N

Means

SD

Gender

Female Male Married Unmarried Not Having

26 26 70 40 23

49.07 47.84 49.00 49.25 48.13

10.20 8.90 10.39 8.51 10.00

Marital Status Health

‘t’ Value 1.62 -0.56 0.45

22 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ Status

Coping Strategies

Health Problems Having Health Problems Utilising Not Utilising

23

48.60

11.00

71 39

48.71 48.53

8.90 9.74

0.40

It is very interesting to note from the Table-6 that none of the personal factors have significantly influenced the sources of pressure in medical professionals. It can be concluded that irrespective of gender, marital status, health status and utilization of coping strategies all medical professionals-both consultants and PGs experience equal sources of pressure. Table 7: ANOVA Results in terms of Sources of Variance, Sum of Squares, Degrees of Freedom, Mean Square and ‘F’ Ratio for Psychological well-being, Job satisfaction, Sources of pressure for Surgical, Clinical and Para clinical Groups. Variable

Psychological well-being

Job satisfaction

Sources pressure

of

Sources of Variance SSB

Sum of Squares (SS) 34.31

Degrees of Freedom 2

Mean Square

SSW

975.41

107

9.11

TSS SSB

1009.72 373.75

109 2

186.87

SSW

23710.67

107

221.59

TSS SSB

24084.42 1154.60

109 2

577.30

SSW

190730.50

107

1782.52

TSS

191885.10

109

17.15

F Rati o 1.88

0.84

0.32

An observation of the above table reveals that there is no significant impact of specialization of the medical professionals (Surgical, Para clinical, Clinical) on their Psychological well-being, job satisfaction and sources of pressure. In other words, the medical professionals in surgical, para-clinical, and clinical specializations do not differ significantly in their psychological well-being, job satisfaction and sources of pressure.

Aminabhavi, Dindigal

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___________________________________________________________ 6.

Discussion

It is very clear from the findings presented in the results that consultants have significantly higher meaningfulness in their life, self esteem, positive affect, life satisfaction, personal control, tension, satisfaction and overall well-being when compared to postgraduates. It can also be noted that although the tension is high in consultants the significantly higher scores in the remaining dimensions have contributed to their higher well-being. As the consultants are more accomplished and experienced in personal and professional life, they find their life more meaningful, experience higher self esteem, positive affect, satisfaction and personal control. This is in contrary to the many studies reported from west. They reported that majority of the doctors had felt that physical health has been affected by their work25, 7, 8. Similarly studies focusing on the consultants’ mental health/ill health have found that psychiatric morbidity is also significant in them. The global prevalence of psychiatric disorders in hospital consultants was 25%28. Other findings indicated that 31% were suffering from mild to severe depression, 12%-18% were depressed and 3-10% having suicidal ideation29,30. The other group in the study i.e., postgraduates reported significantly lower well-being. This may be due to the fact that they are at the beginning of their career, facing lot of uncertainties and also day to day functioning in high stress environment. It was found that they have significantly lower meaningfulness, self esteem, high somatic symptoms, less personal control, general efficiency, satisfaction and wellness. The students have to struggle very hard to get into the postgraduate courses, often they take up specializations that were not their first preference. When they compare themselves with others they feel their inability, hence they have poor self worth. They are so squeezed for time that they find it difficult to handle complex medical and psychosocial issues involved. This finding is supported by some of the studies reported from west. Internal medicine residents were studied in comparison with Spanish sample and found that 7% reported burnout, 18% depersonalization and 23% scored low on personal accomplishments31. The factors that were associated with these were being single, working in speciality, which were not first option, low work satisfaction and low recognition by consultants and patients. Low control, high job strain and work demand led to three fold increased risk of impaired general health32. Other important study found that young doctors experienced less tension, depression, anger and fatigue but more vigour compared to other college students. They also had better scores on perspective taking, empathic concern and lower scores on personal distress before joining internship. Just five months later they were found to be angrier, depressed and had less empathic concern, by seven months it was worse. However after one year some improvement

24 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ was observed; but they never reached pre-morbid levels; i.e., base line scores33. Symptoms of mental illness especially depression is highest in the first postgraduate year34. Hence the present study supports some of the above studies. It is surprising to note that postgraduates, despite having low psychological well-being, have reported higher job satisfaction when compared to consultants. The findings suggest that post graduates have significantly higher satisfaction with achievement, value and growth, satisfaction with organizational design and structure as well as over all job satisfaction. This may be due to the fact that their pursuit of higher studies in the field confirms their achievement and enhances their sense of personal accomplishment and ensures their future potential for growth. The consultants are regular employees of the organization and are more affected by its rules and regulations as well as its design and structure. Due to this fact consultants report lower satisfaction with organizational design and structure. Consultants unhappiness with the way organization functions, its policies regarding patient care, promotions, resource constraints, lack of administrative support and having no say in the decision making are some of the attributable reasons. This finding is supporting the study that found stress and dissatisfaction were associated with lack of time, lack of feedback on effectiveness, day to day bureaucracy and lack of administrative support and lack of consultation about organizational matters35. The postgraduates do not fall under the hierarchy of the organization, hence they are least affected by the above mentioned factors. It was also found that consultants reported significantly higher satisfaction with personal relationships in the workplace. This may be due to the fact that they belong to similar age group (30-40years), have similar life styles, daily routine and interests. Collaborative type of work, physical proximity and prior friendship are some of the other important reasons. Postgraduates have reported lower satisfaction because they are hard pressed for time and give priority to clinical work and meeting the demands of the hectic course. When both the groups were examined for sources of pressure, it was found that postgraduates reported significantly higher pressure in the sources like factors intrinsic to job, managerial role, organizational structure and climate as well as overall scores. This may be attributed to the demanding nature of the course, long hours of work, sleep deprivation, need to perform well in high stress atmosphere, time and resource constraints, mundane tasks involved in the day to day running of the ward, lack of freedom and non recognition of work done. Younger doctors and postgraduates experienced less autonomy and hence reported it as one of the reasons for stress36,37. The finding that consultants’ having significantly higher stress due to relationship with other people may be due to the fact of

Aminabhavi, Dindigal

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___________________________________________________________ professional jealousy, unhealthy competition and favouritism by higher authorities etc. This finding supports the earlier finding of two studies which reported that poor relationship with other doctors and unrealistically high expectation by organization; colleagues and patients are associated with high stress38,39. Further the consultants’ high stress due to career and achievement dimension is because of lack of opportunities and facilities to progress further in the field as well as delayed promotions and no recognition of their contributions. This finding supports the finding of a study which reported lack of recognition of one’s work along with too much responsibility at times, keeping up to date with knowledge and disillusionment with the role of doctor and changing demands are causes of stress in doctors40,41. The medical profession demands constant commitment of the doctors, hence they face difficulty in balancing home/work activities, poor social life and sharing of household responsibilities with working spouse add to already stressed medical professional. In general, many doctors pursue their career at the expense of family and social life; and hence are deprived of the opportunity to participate in activities which are stress relieving. Studies have revealed that doctors reported most stress due to disruption of family life, attending night calls and emergencies during surgery hours42,43. The other reported factors such as interruption of family life, 24-hour responsibility for patient’s lives and working after sleepless nights as stressful. Inability to switch off at home also is one of the major reasons44. Women doctors reported that lack of emotional support at home as one of the major reasons for stress. They experienced conflict between their work and personal lives 45,46,47. The present study found that female medical professionals are having significantly higher psychological well-being than the males. This may be attributed to the fact that these female doctors derive pleasure playing the dual role (home and work place) equally well. More specifically these female doctors have realized that they are capable of contributing to medical profession as well as to home/family life. This very fact makes them to experience higher positive affect, self-esteem, and personal control, wellness and life satisfaction in general. At this juncture it would be interesting to note the explanations offered by social scientists regarding high satisfaction rates in professional women despite multiple stressors. They suggested that women have lower job expectations than men, are socialized not to express discontent and value different aspects of career than do men. Irrespective of gender, married medical professional were found to have significantly high psychological well-being than unmarried ones. This may be due to the fact that they have stable family life, receive social and emotional support from the spouse, which boosts their positive affect, self esteem, wellness, self worth etc. The finding of doctors with health

26 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ problems reporting significantly lower psychological well-being than their counterparts may be mainly due to poor control over themselves, inability to do daily activities efficiently, failing to have high self esteem and positive affect as well as experiencing high tension. As the daily practice of physical, mental exercises such as regular walk, playing, doing yoga and meditation have tremendous impact on the physiopsychosocial health of a person, the same is reflected in the present findings that doctors practicing relaxation techniques have reported significantly higher psychological well-being than their counterparts. Although women professionals have high aspirations, their family bindings, and demands do not allow them to achieve or experience the full satisfaction, this is reflected in the present finding of women reporting significantly lower job satisfaction. Compared to unmarried professionals married ones are well facilitated by various factors prevailing in the family that in turn helps in deriving satisfaction from their job too. The medical professionals with health problems encounter with several problems in their profession and feel unable to function optimally and fulfill the expectation of the field, hence results in significantly lower job satisfaction. Though high pressure and low well-being has been reported universally for postgraduates, nothing much has been done to address this except for a few changes brought about by Royal college of UK. With specific to India, authors recommend that immediate intervention is required to lessen the postgraduates’ distress and enhance their wellbeing. Since they are precious human resources this issue needs to be addressed immediately. Steps like limiting the hours of work, avoiding sleep deprivation, not working the day following night duty, close supervision, regular feedback regarding performance, making academic activities more interesting, encouraging them to involve in extracurricular activities and providing more opportunities to socialize can be taken up to reduce their stress. Helping them to improve their professional skills, enhancing their knowledge are some of the steps that would greatly improve their well-being/ self-esteem and worth. Any organization with high turn over of staff needs to look into its obsolete policies and practices. Appointing staff on ad hoc basis, offering no perks and privileges, poor pay for the highly skilled professionals, delaying the promotions, discouraging the creativity, lack of variety in work, non recognition of capabilities and performance of staff, burdening them with administrative tasks, lack of feedback, failing to provide opportunities for intellectual stimulation to its staff are some of the deterring factors. Employing staff retention practices such as paying them on par with their experience and skills, regularly increasing the pay, improving working conditions, provide more resources, sending staff on sabbatical and other such measures would greatly help in increasing their job satisfaction.

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Notes 1

J.M. Lawrence, “Stress and Doctor’s health”, Australian family physician, 25(8) (1996): 1249-1253. 2 E. Guthrie; D. Black; H. Bagalkote; C. Shaw; M. Campbell; & F. Creed, “Psychological stress and burn out in medical students: A 5 year prospective longitudinal study,” Journal of Royal society of Medicine, 91(1998): 237-243. 3 J. Firth-cozens, “Levels and sources of stress in medical students,” British Medical Journal, 292 (1986): 1177-1180. 4 J. Goaske, “Improving the Mental Health of Doctors,” British Medical Journal Career Focus 327 (2003): s188. (13 Dec 2005). 5 P.G. Tsoutsou, “Improving the mental health of doctors: Do certain specialties need extra help?” British Medical Journal, Career focus on line, 15, December, 2003. 6 S. Cejka, “How to ban job burn out”, Medical economics 76 (1999): 31. 7 A.C. Dowell; S. Hamilton; & D.K. Leod, “Job satisfaction, psychological morbidity and job stress among New Zealand General practitioners,” New Zealand Medical Journal 113 (2000): 269-272. 8 D.B. O’Connor; R.C. O’Connor; B.L. White; and P.E. Bundred, “Are Occupational stress levels predictive of ambulatory blood pressure in British general practitioners? An exploratory study” Family practice 18(1)(2001): 92-94. 9 O. Nedic; D. Filipovic; Z. and Slovak, “Job stress and cardio vascular diseases with health workers” Med. Pregl. 54(9-10) (2001): 423-431. 10 Office of Population census and surveys. Occupational health decennial supplement for England and Wales. London: HMSO, 1995. 11 S. Linderman; F. Lara; H. Hakka; and J. Lonnquist, “A Systematic review of gender specific suicide mortality in medical doctors,” British Journal of Psychiatry 168 (1996): 274-279. 12 H.V. Thommasen; M. Lavanchy; I. Conelly; J. Berkowitz; S. Grazybowski, “Mental Health, Job satisfaction, and intention to relocate. Opinions of physicians in rural British Columbia,” Canadian Family Physician 47 (2001): 737-744. 13 A. Ramirez, J. Addington-Hall; and M. Richards, “ABC of Palliative Care: The Carers,” British Medical Journal 316 (1998): 208-211. 14 British Medical Association. The misuse of alcohol and other drugs by doctors. London: British Medical Association, 1998.

28 Psychological Well-being, Job Satisfaction & Sources of Pressure ___________________________________________________________ 15

R.P. Caplan, “Stress, Anxiety, and Depression in hospital consultants, general practitioners, and senior health service managers,” British Medical Journal 6964 (1994): 1261-1263. 16 A. Branthwaite; & A. Ross, “Satisfaction and job stress in general practice,” Family Practice 5(2) (1988): 83-93. 17 S.L. Belloch-Garcia; V. Renovellfare; J. R. Callabuig Alborch; and L. Gomez Salinas, “The professional burnout syndrome in resident physicians in hospital medical specialities,” Annals. Medical Interna., (2000): 118-122. 18 Thommasen, 737-744. 19 N. Edwards; M.J. Kornacki; & J. Silversin, “Unhappy doctors: what are the causes and what can be done,” British Medical Journal 324 (2002):853-838. 20 Branthwaite, 83-93. 21 J.G. Howie; J.L. Hopton; D.J. Heaney; & A.M.D. Porter, “Attitudes to medical care, the organization of work, and stress among general practitioners” British Journal of General Practice 42 (1992): 181185. 22 T. Durdle, First national membership survey, Health Visitor’s Association, London: Health visitors’ Association. Health Visitor’s Association, 1995. 23 J.K. Dua, “Levels of occupational stress in male and female rural general practitioners,” Australian Journal of rural health 5(2) (1997): 97-102. 24 S. Coomber; C. Todd; G. Park; P. Baxter; & J. Firth-Cozens, “Stress in UK intensive care unit doctors,” British Journal of Anesthesia 89(6), (2002): 873-881. 25 Lawrence, 1249-1253. 26 I. Jaiprakash, and S. Bhogle, “Development of the Psychological WellBeing (PWB) Questionnaire,” Journal of Personality and Clinical Studies 11(1-2), (1995): 5-9. 27 C. Cooper, S. Sloan & S. Williams, Occupational Stress Indicator. NFER-NELSON, Darville House, Barkshire 1988. 28 L. Grassi; & K. Magnami, “Psychiatric morbidity and burn out in medical profession: An Italian study of general practitioners and hospital physicians” Psychotherapy and Psychosomatics, 2000 69(3) (2000): 329-334. 29 Thommasen, 737-744. 30 R. Burbeck; S. Coomber; S.M. Robinson; & C. Todd, “Occupational stress in consultants in accident and emergency medicine: A national survey of levels of stress at work,” Emergency Medicine Journal 19(3) (2002): 234-238. 31 Belloch-Garcia, 118-122. 32 O’Connor, 92-94.

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J. Hopkins, “Interns soon Loose Enthusiasm,” British Medical Journal 324 (2002): 1478. 34 R. Tyssen; & R. Vaglum, “Mental Health problems among young doctors: an updated review of prospective studies,” Harvard review of psychiatry 10(3) (2002): 154-165. 35 Durdle, 1995. 36 Dua, 97-102. 37 Tyssen, 154-165. 38 Branthwaite, 83-93. 39 Shropshire Medical Audit Advisory Group, “Results of General practitioner stress audit,” Health magazine, 1993, 1-2. 40 Coomber, 873-881. 41 Branthwaite, 83-93. 42 Howie, 181-185. 43 V.J. Sutherland; & C. Cooper, “Identifying distress among GPs: Predictors of psychological ill health and job dissatisfaction,” Social Science medicine 37(5) (1993): 575-81. 44 Shropshire Medical Audit Advisory Group, 1-2. 45 Howie, 181-185. 46 Sutherland, 575-81. 47 R. Chambers; & I. Campbell, “Anxiety and Depression in general practitioners: Associations with type of practice, fund holding gender and other personal characteristics,” Family practice 13(2) (1996): 170-173.

Authors *Dr.Vijayalaxmi.A.Aminbhavi, Reader, Dept. of Psychology, Karnatak University, Dharwad 580 008, Karnataka, India. **Ajitha Dindigal, Research Student, Dept. of Psychology, Karnatak University, Dharwad 580 008, Karnataka, India

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Evaluation of the Historical Recent Past: Humour as a Possible Collective Coping Strategy Judit Ujlaky Abstract In communicative memory the revision of collective memory and the social representation of history take place from time to time. These representations are narratively formed; they function in different social groups as folk histories, naive stories about history, according to the social identity needs of the groups. From the stories about history which are present in a group, we can come to conclusions about the characteristics of social identity, framed within the field of social psychology. Telling and creating jokes is a dominant form of urban life, a special aspect of historical memory. It is a widespread standpoint that laughter reduces stress and anxiety, and is a decisive way of coping. The study of jokes goes beyond this approach, because in jokes we can identify social elements as well, not just individual ones. 1.

Introduction

History plays an important role in the functioning of all communities. Knowing about the history of a group reinforces and guarantees membership in that group (i.e. without knowing the history of our group we are not considered as plenipotentiary members), makes a sense of social identity possible, and moreover, our present experiences depend on our knowledge of the past. Accordingly, historical events are not taken for certain, the same event is assessed in diverse ways by opposing groups, and even within a group the historical facts are rediscussed from time to time, new facts emerge and make the events seen in a different light. So to say, the past is always is the result of social construction. History itself (as a science) is always searching for the truth, although several thinkers doubt its objectivity1. The common feature in all of these approaches that they consider fiction as the actual category of narratives, therefore even the narratives of history obey the aesthetic criteria of narratives, accordingly, historical reality and fiction get mixed up. As Connerton says, historical reconstruction is …depending on the narratives written by the witness of some scene, what the historian deals with are traces:...the marks, perceptible to the senses, which

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___________________________________________________________ some phenomenon, in itself inaccessible, has left behind....it is still possible for the historian to rediscover what has been completely forgotten...the historian will need to question that statement if it is to be considered as evidence2. But knowing about history means not just this official, truthoriented approach. Social memory research aims to identify the social aspects of memory, remembering and forgetting. Approaches are rather diverse, but some common themes can be traced3. 2.

Remembering Together

These pieces of research “examine how people collectively constitute and function as integrated memory systems4”. None of the members of a group is capable of achieving certain knowledge, certain feelings without the group. For instance, we never met our greatgrandparents in person, but from the narratives of our grandparents and parents we could recall a lot of facts and emotions from their lives which is transferred towards us as models; how to feel, how to behave in a given situation, so our future actions and emotional states are influenced by these models and interactions. 3.

Social Practice of Commemoration

Some events and persons gain historical importance and we commemorate them officially. All the national commemorations belong to this facet of research. 4.

Social Foundation and Context of Individual Memory

The society provides frameworks in which we learn what is worthy enough to remember. This approach is slightly different from the previous one, since rituals and commemorations follow a more or less fixed practice, but the frameworks are formed by conversations and debates among the members of a society. Moreover, “even the catechismy and ceremonies of ritual commemoration are the product of conversation and argument5”. 5.

Narrative Organization of Remembering and Forgetting

Bruner6 suggests that human thinking has two forms, pragmatic and narrative. The latter form of thinking refers to making sense and coherence of the world. According to him, if we tell stories, we do not

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___________________________________________________________ report the events but we give sense to them; we attribute psychological states to the actors. There are right stories and there are wrong ones, but it depends on the ways we create the story and not on the truth of the story. A psychopath could deceive anybody with a story, because of the structure of his or her narrative and not because of the truth of it. In a society the truth “is not to be found unambiguously deposited in some objective social record or archive...It obtains...as an epistemological enterprise created in dialectic and argument between those contrary positions7”. Even speaking is basically to guide our social actions, “we speak in order to create, maintain, reproduce and transform certain modes of social and societal relationships8”. 6.

Social Institutional Remembering and Forgetting

This point refers to how social institutions allow or ban remembering and forgetting. Under dictatorial regimes, only the ruling power has the right to define the aspects of everyday life; the past, present and future. They define the identity of the controlled group. 7.

The Forms of Social Practices in the Continuity of our Lives

The socio-cultural practices determine the individual - its mind, and its integrity. So, in this case, there is no point in making a distinction between individual and social - they are interdependent. All of these notions are centred on one particular concept, the idea of identity. As Cavalli9 mentions, history is oriented toward the truth, memory is oriented toward identity. (...) The claims of identity will inevitably tend to overwhelm the claims of truth. Only in pluralistic democratic societies can they converge, but they never will coincide10. In my analysis, the concept of identity plays the most important role. As we will see, joking about the past (or understanding a joke about the past of the nation) creates the sense of togetherness, and gives another notion about coping with humour. The difference between historical reconstruction and social memory has more aspects. In social memory, there are no objective traces and they cannot be objectified, the traces are already in the memory, and these traces follow the identity need of the trace-holder community. Forgotten facts cannot be recuperated, excavated from the social memory, but historians are able to discover totally new objects, relations, facts. (However, this latter notion is slightly problematic, because the official

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___________________________________________________________ history can modify the social memory, this should be the main goal of historians: inform the peers and the wide public about the truth, although historians’ work is dependent on the identity needs of a group.) Historians question mainly the statements of the witnesses, but social memory questions the witness itself, however true the statement is, if the source of it is not acting according to the identity needs of a group, all of his or her statements will be rejected. (See the political debates between governing parties and opposition. None of the utterances will be approved by the opposing party.) In psychological literature there is the concept of social representations,11 which can cover all of these notions in one theory. Social representations are loose webs of ideas, metaphors and images and they change more rapidly than the theories themselves. These representations are carried by the communication, so they are narratively formed. Moscovici assumes that just some aspects of the theories are represented within the communication and other -equally important aspects are neglected. If even historical events act this way, only those aspects of the events which are represented in the communication remain in the social memory. By nature jokes are also narratively formed, ideal tools of carrying social representations. Political jokes carry the main features of the politics, in this case it is indifferent whether they are problematic or not. Social memory and current discourse preserves these jokes and also these jokes reconstruct the past. If we hear a joke, this illuminates the crucial events during the life of the group that we belong to, so it gives us the sense of identity. If there is a change in the outer world, necessarily there will be a change also in the identity; so, there is a shift in the psychological status, from the old to the new. “During the life of every individual, group, community or even large society, events occur which mark turning points in its life course. These events structure the flow of time and divide it into ‘what was before’ and ‘what came after’12. All these so called crucial events mark discontinuity, challenges to our identity, and as a consequence, we have to reconstruct our sense of continuity, re-evaluate and revise our identity. Some authors argue that there is no need to make a distinction between personal and social identity, because the outer events influence our ‘personal lives and everyday activities’13, moreover, stress deriving from societal problems has a strong effect on our ‘selfconfidence, independence and personal identity’14. According to Cavalli15 there are three different patterns of dealing with memory which human societies follow when ‘constructing collective identities’. The most important one for our topic is the so-called zero point pattern. When discontinuity is maximized, a society takes a very new start, the critical event -which divides time into ‘before’ and ‘after’ - is monumentalized and ‘celebrated as re-birth’. Monumentalization appears in material and in

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___________________________________________________________ ideological sense, too. In this case, the future is the entity, which determines the society’s identity, “what matters is not what we have been but what we want to become”. If the aspiration of the new regime is total changing, forced forgetting becomes the main aim of the ruling power. Totalitarianisms work according to this notion. Dictatorial regimes do not allow their citizens to remember the past (differently) and do not give the right to think about the future in diverse ways. Jokes can work as means of coping, which guarantee the feeling of continuity, because other voices are repressed. As Halbwachs16 mentions, memory is collectively determined, but it is also ideologically determined, the processes of memorization are parts of the ideological pattern. Ideology is used for ‘reproduction of power relations’17. So, not just the present problems give shape to a new ideology but the new ideology itself forms the memory of a society. In a totalitarian regime other voices than that of the power are muted, alternative versions of history are banned. In this situation jokes appear as holders of the continuity of identity. The rhetoric, the narrative of the ruling power itself can be true but it always challenges the identity of the community, and necessarily there will be underground voices, which attempt to regain the continuity. In a society under totalitarianism, where also economic problems appear, the threats are even bigger and have deeper effects on identity, because economy shape the circumstances of life and the citizens lose their control over their knowledge of economic facts, so they will not understand how economy is working18. In this case people need to mobilize their emotional and intellectual forces (so coping mechanisms) to deal with these problems. Within the domain of psychology, humour is considered as one of the tools of coping, an effective coping strategy that is only used by mature persons. Unfortunately, humour theorists frequently fail to connect or compare other coping mechanisms with humour, they just refer to it as a possible coping strategy but do not consider its relation to the other ones. So, there is an interesting vicious circle if we try to define the two concepts (i.e. the concepts of humour and coping). We identify humour as one of the healthiest, the most mature coping mechanisms, meanwhile we happily recognise that those people who apply humour as a coping strategy are healthier not just psychologically but physically as well. For these “humorous people” there is the possibility of using not just humour but other effective ways of coping and not the pathological ones, the ability of using humour as a coping strategy automatically means that the person has an enhanced coping potential. Indeed, there are several mediators, but researchers constantly fail to analyze this question at a higher level. There are two different concepts of humour as a coping strategy: a cognitive and a biological approach. the cognitive re-structuralisation of the situation, so the transformation of threat to challenge and the

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___________________________________________________________ competitive inhibition of negative thoughts, that is, meanwhile we think of something in a humorous way, other ways (which are usually more threatening and less effective in terms of overcoming the present situation) are blocked. The other concept is about the effect of laughter on bodily state, so cardio-vascular improvement, fostering of production of endorphin and so on. However, all these theories apply an intrapersonal approach. The interpersonal approach, especially the effect of humour on a group is considered in conversational humour research, but the two approaches are rarely combined. From the psychological research of humorous interactions between individuals we have a vast amount of data about conversational humour. Telling political jokes is a special case in this field because they reflect upon a broader, more abstract group, but they are also based on and serve for identity construction. Moreover, as one could be sentenced to prison for telling a joke, the teller should have been very careful and tell jokes just in a very safe community. (Certainly, even in a dictatorship there are humorous magazines, but they serve the ruling forces and are censored). So, the political jokes are about a bigger, more abstract group and the jokes themselves appear in a small, virtual group with well-known members. Douglas19 mentions that there is a direct relationship between humour and social structure. We tell jokes because the organized patterns of life are contradictory, incongruous, humorous utterances necessarily involve a confrontation with the dominant social pattern. So, joking is generated by the social structure but at the same time as it challenges, it disrupts it by provides enlightenment of its incongruities and irrationalities. Political jokes also give voice to opposing views, they tell the truth about the irrational political and economic paths in dictatorships. The relationship between humour and coping is frequently analysed along the comparison between the seriousness and number of negative life events and perceived level of stress. However, negative life events are only important in a special sense: when they cause negative emotional states. Moreover, all of the events that can lead to a mood alteration should be considered. On the lists of the most stressful life events there can never be found the historical-political atmosphere of a country, although it is a rather important source of stress and negative emotions, especially if we examine an autocratic, totalitarian state. The literature deals with them as they were two totally different entities.20 As if the identity of a person would not be equally personal and social. As we have seen before, the social aspects of life determine the self and personal identity; therefore we cannot make a clear distinction between these concepts of identity. Moreover, researchers deal with threat if only the responses to it were different, if a threatening situation would be unidimensional, i.e. if we should cope with a situation, not just one aspect

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___________________________________________________________ of it can be considered as threatening. A threat to a nation could mean a threat to the individuals at the same time, and vice versa. A person can be threatened also in his or her social identity is threatened. If there is a discussion on this matter, it covers just either a smaller group, and this approach cannot say anything about a more abstract, and complex macro structure, like a nation is (i.e. psychological approach), or covers just the macro system which has nothing to do with the actual status of the members of that group (i.e. a sociological approach). If we try to understand the psychological mechanisms and the life of and in a dictatorship, there is a need to investigate these two levels in parallel. If we do so, a more sophisticated picture would be seen. Benton21 argues that real political jokes can only appear in dictatorships - as responses to acute tension and inhibition.22 In the Western, political jokes about democratic societies are told by professionals; they are harmless, they circulate within official channels, and the right to tell them is one of the citizens’ freedoms. Whereas in a dictatorship, political jokes give a unique point of view into the problems of everyday living, and they are an inherent part of it maybe because they are the least dangerous means of expressing the real, non-official opinion of the society. Larsen23 states that in a dictatorial regime the one and only means to elude censorship is jokes, because there is no one to blame, there is no one to be punished because we cannot identify the inventors of the jokes and if the oppressors fought back they would become even more ridiculous. Benton24 also mentions that political jokes are present only in those societies where one’s public face no longer matches their private feelings, where there is a gap between self and society. We would like to argue that this discrepancy does not mean a discrepancy between personal and social identity as a consequence, just a difference between real, selfmade identities and forced, arbitrary changed identities. In some cases not all of these forms of identity are contradictory. When the radical historical-political change meets the psychological needs of a society, it can even hide the economic difficulties and problems of discontinuity for a while. In the case of those societies where the positive outcomes cannot compensate for the losses, and the possibilities for acting are highly limited, jokes are the one and only means of action to be able to change ideas and form public opinion. Though Benton25 claims that even in a dictatorship jokes keep the people happy and it would be rather foolish to deal with them too harshly (i.e. sanctioning joke telling), therefore permitting jokes against the state is clever insurance against more serious challenges to the system. He derives his argument from analysis of jokes from the Soviet Union, which is (or at least was) one of the most powerful military forces of the world. Despite serious economic problems, they ruled over half of Europe and Asia. The other countries of the Eastern block were much smaller and

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___________________________________________________________ less resourceful than the Soviet Union, therefore they did not have the possibility to act against communism because when they tried it (for example in 1956 in Hungary or in 1968 in Prague), the uprisings ended in bloody defeats. And the attempts meant more serious control and reprisals. That is to say, where even the desire of changing is impossible, political jokes have a more important role. When examining political jokes, we should always consider the social identity needs of a nation; not even the dictatorships are psychologically the same. In a dictatorship there are just a few means against the regime. After a failed revolution there is no other means besides jokes to be able to re-strengthen the opposition towards authority and to be able to feel the real social support and the real needs and thoughts of the muted masses. Moreover, during communism, it was prohibited to talk about certain national problems; in the case of Hungary we can cite the example of the Trianon Peace Treaty, which was the treaty at the end of the World War I. After this treaty, two-thirds of the Hungary’s territory was taken away to be joined to neighbouring countries, economic life was paralysed, and a totally new state was built up. That is, in the communist era different layers of national identity were touched at the same time. Hungary, because of its last 100 years of history, is a very exciting phenomenon from a psychological point of view. About 100 years ago Hungary lived its most prosperous period, although under foreign influence (Austro-Hungarian Monarchy). Ending the first World War, the Trianon Peace Treaty, which I have already mentioned, was signed. The great depression also shocked the country and in World War II Hungary chose the wrong side again. After it, a totalitarian communist regime ruled the country, the uprising against communism failed in 1956, the Russian army remained in the country and from the 70s a relatively calm period began but again without independence. After the change of regime we have to learn how to make a democracy work, and in fact what the true meaning of democracy is. Practically, during the last century in every 20 years Hungarians were forced to re-define their social/national identity, in every 20 years a new regime came and wanted to take a brand new start (which meant the re-definition of the history), but the identity needs to feel the continuity, and this sense of continuity is guaranteed by realising our role and faults in our own history and cope with them. During the decades of communism the severity, the seriousness of political humour changed, too. In the 50’s some political jokes were labelled as 2/3, which meant at least three years in prison for the storyteller and two for ones not reporting him. Later, about from the 60’s jokers risked less but still it could be dangerous to one’s social standing if caught in public in the act. Then in the 70’s it became like a government tolerated hobby, wisely seen by the authorities as something to let off the excess steam from the system. Here I would like to refer back to Benton’s

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___________________________________________________________ argument about the foolishness of the leaders if they sanctioned joke telling. If it would be so, there could not have been so many - let’s call them - meta-jokes, i.e. jokes about the dangers of joke-telling. In the 80’s political jokes got half-legalized, meaning of course that joke telling was never outside of family or friendly circles. However, jokes have been circulated in the Eastern block, that’s why many of them are very much international, in the best sense of Communist internationalism. And that’s why we cannot identify the source of the jokes, but when I use them, I refer to them as Hungarian ones. Nowadays there is a big nostalgia for the jokes of communism when almost everybody thought the same and a national unity was experienced, the problems were easy to identify (although problem-solving was impossible). The present problems are not so serious but more complex, so the level of tension is obviously the same. The jokes became Western style, the conservative and the social-liberal sympathizers tell jokes about one another and everybody tells jokes about police officers. However, in 2002 the parliamentary elections were rather fierce, the opposing parties argued against each other and not for their own ideas and programme. Both parties’ (2-2 political parties in each side) supporters told jokes and sent caricatures to their friends and acquaintances by SMS (text messages sent via cell phone) or e-mail26. By the end of the campaign everybody knew which party everyone else belonged to. Humour was used to reinforce social identity, in this case social identity means the membership in or being ideologic supporter or voter of a party. In this article I have argued that jokes have a highly important role in discussion and re-discussion of political problems since they act as social representations and even in totalitarian regime they function as alternative stories about the current problems, they can live in the memory of a certain group and they can function as means to ensure continuity in the discourse. In addition, jokes are present in a stressful situation not only because they can reduce stress but also because they act as identityreinforcers.

Notes 1

See the works of the Annales circle, for example F. Braudel (ed.), On History. Chicago: Chicago University Press, 1980. F. Furet, “Quantitative History,” in Historical Studies Today, ed. F. Gilbert and R.S. Graubard. (New York: Norton 1972), 54-60. J. Le Goff, and P. Nora (eds.), Constructing the Past. Cambridge: Cambridge University Press, 1985. semotic approaches as

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___________________________________________________________ R. Barthes, “Introduction to the Structural Analysis of Narratives”, in Narratology, ed. S. Onega and J. A. G. Landa (New York: Longman, 1996), 45-60. T. Todorov and O. Ducrot, Encyclopedic Dictionary of the Sciences of Language, Baltimore, Oxford: Johns Hopkins University Press, 1979. anglo-saxon analytical philosophy, C.A. Danto, Analytical Philosophy of History, Cambridge: Cambridge University Press, 1965. D. Carr, “Die Realität der Geschihte,” in Historische Sinnbildung. Problemstellungen, Zeitkonzepte, Wahrnehmungshorizonte, Darstellungstrategien. Rowohlt Taschenbuch Verlag: Reinbeck bei Hamburg, 1997, 309-328. L.O. Mink, ‘Narrative Form as Cognitive Instrument’, in The Writing of History: Literary Form and Historical Understanding ed. R.H. Canary & H. Kozicki (Madison: University of Wisconsin Press, 1978), 127-144. and the hermeneutic approach, P. Ricoeur, “Explanation and Understanding: On Some Remarkable Connections among the Theory of the Text, Theory of Action, and Theory of History,” in The Philosophy of Paul Ricoeur: An Anthology of His Work, ed. E.C. Reagen & D. Steward. Boston: Beacon Press, 1978. 2 P. Connerton, How Societies Remember. (Cambridge: Cambridge University Press, 1989), 13-14. 3 For a review see D. Middleton & D. Edwards, ‘Introduction’, in Collective Remembering, (London: Sage Publications, 1990) 1-22. 4 Middleton and Edwards 1990; J.V. Wertsch, “Collective memory: issues from a socio-historical perspective,” Quarterly Newsletter of the Laboratory of Comparative Human Cognition 9.1 (1987): 19-22. 5 Middleton and Edwards 1990. 6 J. Bruner, Actual Minds, Possible Words. Cambridge, Mass.: Harvard University Press, 1986. 7 Middleton and Edwards, 1990, 9. 8 J. Shotter, “The Social Construction of Remembering and Forgetting,” in Collective Remembering, ed. D. Middleton & D. Edwards, (London: Sage Publications, 1990), 121. 9 A. Cavalli, A. Patterns of Collective Memory (Budapest: Collegium Budapest, Institute for Advanced Study, 1995). 10 Cavalli, 1995, p. 13. 11 S. Moscovici, “The history and actuality of social representations,” in The Psychology of the Social, ed. U. Flick (Cambridge: Cambridge University Press, 1998) 209-247. 12 Cavalli, 1995. 13 Cavalli, 1995, p. 4.

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___________________________________________________________ 14

Shaw Bell, C. “A Sane Economy for a Sane People,” in Coping in Troubled Society ed M.R. Just, C Shaw Bell, W Fisher, & S.L. Schensul (Lexington, Mass.: Lexington Books, 1974), 9-37. 15 Cavalli, 1995. 16 M. Halbwachs, The Collective Memory. New York: Harper and Row, 1951/80. 17 K. Thompson, Beliefs and Ideology. Chichester: Ellis Horwood, 1986. 18 Shaw Bell, 1974. 19 M. Douglas, M. “The Social Control of Cognition: Some Factors in Joke Perception,” Man 3 (1968): 361-76. 20 Indeed, the biggest part of the literature on coping comes from AngloSaxon countries, where there have not been many threatening historical-political situations since coping research has begun. 21 G. Benton, “The origins of the political jokes”, in Humour in Society: Resistance and Control ed. C. Powell & G.E.C. Paton (Basingstoke, Hampshire, London: Macmillan, 1988) 17-39. 22 Not in all kinds of dictatorships are these jokes characteristic, for example in military dictatorships, where brutality and force are the preferred means of control. Political jokes can only appear in those situations where there is a concern to “re-shape society’s spirit” or “create a new man” -i.e. when spiritual violation and outrage takes place (Benton, 1988). 23 E. Larsen, Wit as a weapon. The Political Joke in History. London: Frederick Muller Limited, 1980. 24 Benton, 1988. 25 Benton, 1988. 26 Short messages sent via mobile phones, if we want to send them en masse are expensive (compared to e-mail), and the technique was not developed enough to use them for sending moving pictures, so folkloristic elements were more prevalent on the internet. (M. Sükösd and E. Dányi, E-mail és SMS a 2002-es választási kampányban, source: www.edemokracia.hu/program/smskampany.php. 27 Jokes of the (not so) Humorous Struggle Against Communism in Hungary. Budapest: NOTESz + K Ltd., 1997.

Appendix Jokes from the Communist Era in Hungary27 A. Meta-jokes A man asks his friend: - Have you heard a good joke recently? - Of course, I sentenced its teller to prison for 3 years right now.

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___________________________________________________________ B. Historical re-discussion, creating coherence in the history (vs rewriting of it), nostalgic feelings - Why is Hungary so small? - It’s a computer file called Gavrilo Prin.zip C. Not in the USSR, social identity needs In a conversation in a café the parties analyse the present situation. One of them mentions the Turkish conquests. But another interrupts him: All right, but we shouldn’t have to say out loud that “Hail to the Turkish Army”. D. Moral and intellectual superiority of the in-group (Russians, leaders), refusal of power-holders - What is the difference between the director and a train? - A train has two classes, the director has none. E. Positive expectancies, wish-fulfilment, anticipatory jokes - What will be the name of Lenin Avenue in 2000? - I don’t know. - Do you trust so much in the system? F. Control, interpretation of irrational situations The Hungarian national soccer team won against the Soviet Union. The Soviet leaders send a telegram with the following text: Congratulations to the Hungarian guys STOP. This is the real football STOP Crude oil STOP Natural gas STOP. In 1955 somebody knocks on the door at midnight. The owner awakes and asks with fear: “Who’s that?” “The Death” answers a voice. “Thanks to God!” says the owner, “I thought it was the Authority for Defence of State.”

Author Judit Ujlaky, PhD student, Univerity of Pécs, Institute of Psychology, Hungary E-mail: [email protected]

The Medicalization of Emotions: Happiness and the Role of General Practice Louise Woodward and Ian Shaw Abstract Depression as we understand it would not have been recognised fifty years ago, and diagnoses of depression was rare. Recent reports suggest that 1 in 4 people who attend General Practitioners surgeries in the UK have depression, and this trend is reflected across the European Union. Following a review of the medicalization thesis, this phenomenon is explored to gauge the extent to which it could be accounted for by the medicalization of unhappiness. This paper considers the extent to which emotional rather than clinical need is transforming the medical encounter and role of General Practice. 1.

Introduction

The concept of medicalization has received increasing attention over the past three decades 1. Whilst earlier work tended to focus upon the medicalization of deviance 2 this soon extended to the application of the concept to a wide range of human behaviours and, arguably, emotions. Debate has taken on different forms, and generally fallen within one of two camps: initially, the focus has been upon the illegitimate influence health professions have displayed over patients 3. In particular, how doctors increasingly capture and claim exclusivity over areas of social life. An example of this can be seen in the increasing medicalization of child birth where, a large number of healthy people are treated with a barrage of medical and pharmacological techniques in surgeries, hospitals and clinics for a ‘natural’ and ‘normal’ condition (which) has to do with specific management of reproduction 4. Over the years a vast literature has developed reporting on the medicalization of various problems, with particularly attention given to the medical domain 5. A second aspect of the debate to have emerged in more recent years gives consideration to the medicalization of daily living. Thus, high rates of medicalization may be indicative of systemic problems in Western Society and consequently the notion of the population itself medicalizing problems is an increasingly important extension within the debate. Of

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___________________________________________________________ importance here is the individualisation process taking place throughout Western societies, and how the emotional base to modern living may be driving people’s motives for seeking help. Through considering the significance of emotional presentations in attendance at general practice this paper argues for clarity on conditions which may be more effectively assisted by medical treatment, and patterns of consulting behaviour that would benefit from a more socially oriented approach. Emotions can be described as ‘social things, controlled and managed in our everyday lives which transcend the divides between nature and culture, structure and action’ 6. Levels of unhappiness prevalent today might be driven by wider societal problems rather than clinical need, and reflected in the presentation of common mental health problems within primary care. Emotions can be seen as a form of social currency and becoming an increasing aspect of medical encounters. Linked to this debate is the extent to which the public is driving the medicalization of emotions and the extent to which this may be influencing the activity of general practitioners. 2.

The Medicalization Thesis: An Overview

The medicalization thesis essentially refers to the increasing use of medical labels to behaviour that is regarded as socially or morally undesirable 7. The concept however has enjoyed a number of varied definitions. It can be defined as the power and influence of the medical profession, in primarily serving themselves rather than their patients 8. This concerns doctor’s attempts “to enhance their position by presenting themselves as possessing the exclusive right to define and treat illness” 9. A more basic interpretation however sees medicalization as the illegitimate extension and influence medicine has on issues that it is in fact not professionally competent to make such decision. Psychiatry, for example, is regarded as having a pre-occupation with deviant behaviour and controlling that behaviour which is labelled as ‘bad’ 10. As far back as the early part of the twentieth century public health was high on the government’s agenda. Post second world Britain witnessed a Mental Hygiene Movement, its focus upon reducing those social ills caused by mental disturbance 11. This was sought through the promotion of mental welfare and mental hygiene and it was here that the rationale for a new `social psychiatry’ developed, which located the cause of many ills in society as a direct result of an individual’s mental health. Such behaviour was to be controlled or, if possible, prevented by “education, early detection of signs of trouble and prompt and efficient treatment” 12. This preoccupation with control and managing social behaviour has led the profession, at times, to make claims to medical advancements based upon minimal evidence.

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___________________________________________________________ At the heart of the medicalization critique is the idea that individuals should be constrained by the medical profession 13. A second point therefore concerns professional power in relation to the patient’s position. Illich 14 suggests that people’s health is undermined by today’s medicine through judging lay people’s inability to determine their own healthcare without expert advice. The implicit argument lays claim to the limited medical knowledge lay people possess which places them in a vulnerable bargaining position with their GPs, and increases the powerlessness of the sick person 15. Consequently this can lead to an over reliance upon the professional diagnosis. It has been suggested that “research undertaken on the doctor-patient relationship have focused on ways the medical consultation facilitates power of doctors over patients and supports capitalist ideologies” 16. Relationships which exist between doctors and patients are suggested to be a clear illustration of this power imbalance. Recent developments however, such as the ‘user’ movement, especially within mental health, increasing access to information and public involvement in directing NHS Healthcare may have to some extent contributed to re-addressing this imbalance. Medicine can also be seen as illegitimate in deflecting cultural challenges to the existing social and cultural order by transferring them into individual problems rather than viewing them as collectively or structurally caused. Concerns are raised over social problems becoming de-contextualised by the medical model, and consequently where biographical solutions are sought for systemic contradictions 17. Eaton suggests “the system has expanded to define a wider and wider range of behaviours as medical Illness” 18, and which point we would add it also lends itself to increasingly capturing a wider range of human emotions. Advocates of the medicalization critique 19 suggest that virtually all of our day to day activities have been illustrated by medical representations of what is normal (health) and what is abnormal (ill health), suggesting that our entire existence is becoming medicalized. 3.

Depression or Unhappiness

“Emotions, as a social currency, vary in their rates of exchange and validity” 20. Given the often sensitive disclosure of information between doctors and patients, ‘the medical encounter is an ideal arena for emotional expressivity 21’. This leads us to consider whether in fact an emotional ‘narrative’ is developing within primary care and why that may be? Is the situation indicative of deficiencies within wider society; that is, expressions of feelings and emotions that once were part of daily interaction are no longer available to people? As the emotional context of individual life would have formed part of daily living and interactions with one another, this has somewhat declined over the past century,

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___________________________________________________________ whereby emotions have ‘become banished from Western thought and practice, and become a pathologized state 22’. With this in mind, it is not too difficult to comprehend the view that ‘patients now a day bring more than just their bodies and diseases to the medical encounter’ 23. The extent therefore to which the medical encounter is becoming a place of emotional interaction is of increasing importance when contemplating the role of general practice. Psychologist Oliver James, asserts that we should be feeling ‘happier’ and ‘contented then ever before 24. In comparison to economic conditions of the past the Western world is now economically prosperous, where levels of real income has risen, employment has experienced variable rates of growth, and levels of personal autonomy in relation to lifestyle choices such as home ownership have increased; yet apparently not. According to some 25 we are actually more ‘miserable’ today. Evidence suggests that in Britain levels of ‘happiness has been static since 1975 and, based on less firm data, is indeed no higher than in the 1950s’26. It is of surprise then to learn that the richest quarter of Britain have more or less doubled their living standards and have become no happier, whilst simultaneously, the poorer sections of society have become richer and no happier’ 27. It is argued there exists a ‘happiness gap’ within society accounted for by the ‘chemical reaction’ 28 to the “difference between the dreams we are sold and the daily reality of life in advanced capitalism” 29. If as evidence suggests more and more people are attending general practice with common mental health problems, such as anxiety and depression, questions can be raised over the nature of ‘mental’ health and emotional life in general. Perspectives vary on the significance and interpretation of emotions within society and upon emotional well-being. Theoretical contributions to the field of sociology of emotions in particular are extensive, of which two will be mentioned. Emotions are viewed from one perspective as ‘specific ways if being in the world’ 30. Through accounting for emotions in this way, it reduces the attraction to view them as negative, or a failing of the individual 31. Others maintain the existential importance of emotions to the embodied being and their interaction with social life 32. When considering how emotions might be manifesting and coming to the attention of the medical profession, one question that can be raised relates to the appropriate emotion for the illness within which people seek help; that is the extent to which emotions present during a GP consultation 33 are a ‘normal’ reaction to the effects of a clearly defined mental health condition. And which however can be understood as emotions masquerading as illness? In terms of the latter, general practice may therefore be responding to increasing attempts at emotional exchange. To some extent this can be accounted for by the transformations occurring within society over the last century where emotional terrain has been

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___________________________________________________________ subject to change and perhaps to varying degrees removed from the social map. The concern within this paper is how emotions today are experienced and translated to the medical encounter. If we consider the view that emotions represent a way of being in the world, and consider ‘agency’ within help seeking behaviour, then the presentation of unhappiness within general practice might be based on individual reasoning behind the emotion and the action taken is a consequence of such reasoning; that is to consult general practitioners. It follows therefore that ‘unhappiness’ is regarded first and foremost as a ‘condition’ to be treated by the Doctor, largely through pharmacological interventions., and not a human emotion responsive to the wider emotional and social context. Unhappiness, in this instance, becomes understood through depression constructs, a condition treatable by the medical profession. To a large extent unhappiness within society seems to be viewed as an inappropriate emotion as public tolerance for it decreases, with the emerging medicalization of human distress. Perhaps the increasing medicalization of deviant behaviour and social control can be seen in the way depression has become prevalent in the past decade. The apparatus of treatments and social control, with particular reference made to antidepressants, has increased in the last decade with 17.5 million Benzodiazepine prescriptions issued by GPs in 1999 34. A possible explanation for this may be found in the alienating effects of a changing individualistic and competitive world. It has been argued that alienation within contemporary society is increasing and has become manifest in the medicalization of social problems; “new forms of illness are being called into being, and boundaries of existing illness definitions extended within biomedicine and culture at large” 35. The argument follows that during a climate of social alienation the context of the self is important, as it becomes an object of intervention. The social, cultural, economic and emotional context of the individual is all important and it is this context which illustrates how ‘depression’ has become positioned within contemporary medicine 36 and consequently, how non-medical problems, have become increasingly medicalized 37. Zola 38 suggested a process which ‘mystifies the inter-relationship between the individual and the wider social and economic structures’. Individuals, in this sense, are becoming defined and labelled through depression constructs. There are a number of life events that cause people distress but a key issue is the extent to which the unhappiness that results from this is tolerated or not. Unhappiness now is seen as depression, an emotion that is social in context rather than psychological 39. It is suggested that contemporary medical psychiatry has, in large, maintained it’s scientific view of mental illness to maintain its status within medicine. As a result, “sadness has been re-named ‘depression’ and becomes not a human

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___________________________________________________________ emotion, brought on by the effects of complex social and personal interfactors but, a pathology residing in a dysfunctional individual” 40. The control of emotions by modern psychiatry is evident through the increasing everyday usage of psychiatric terminology. This implies that a normal human reaction to a given event can now be classified as a condition that is treatable by the medical profession 41. In his famous polemic, Bental noted his surprise that happiness was not classified as a disorder: “It is proposed that happiness be classified as a psychiatric disorder and be included in future editions of the major diagnostic manuals under the new name: major affective disorder, pleasant type.” 42 The increase in medical categories appears to support the notion that medicalization is taking place. A key component here however is to what extent these categories are being developed through society’s increasing demand for a quick fix to what is perceived as depression but may be emotional in content. Conrad 43 suggested “the extent to which medicalization is increasing is not simply a result of medical colonisation”. This is a pivotal point within the medicalization debate. Zola very much underpinned this concept through a further definition of medicalization, which sees it as “an insidious and undramatic phenomenon accomplished by ‘medicalizing’ much of daily living, by making labels ‘health’ and ‘ill’ relevant to an increasing part of human existence” 44. It is further argued that the current classification system (DSM) for psychiatric disorders ‘reflects a combination of public and professional attitudes towards the origins of deviant behaviour and how it would be controlled’ 45. This only refers however to a small percentage of referrals from doctors to psychiatric services. If it is becoming more acceptable for new illnesses to become caught up and re-defined within the medical diagnostic criteria then the public at large are medicalizing problems. Taken one step further, a process of individual medicalization is taking place in conjunction with the medical response to increasing demand. This challenges the traditional view of the patient’s vulnerability and powerlessness within their bargaining position with the GP. As society has become more adept at problem solving within the medical realm, so a discourse has developed in which health is seen as a basic human need, and medical care has become perceived as a social right. 4.

Expressions of Emotions Within Primary Care

The presentation and treatment of common mental health problems, such as anxiety and depression, within primary care have increased in recent years whereby many patients are presenting with both of these conditions. 46 According to recent research the increasing prevalence of anxiety and depression are seen as ‘engendered by the

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___________________________________________________________ interaction of social, psychological, organic and circumstantial factors rather than simply clinical ones’ 47. Perhaps by considering the presentation of depression as ‘non clinical’ in motivation, it provides a context where we can begin understand how emotional need is being reshaped and presented within society.

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Community Attending Identified by Referred tp Admitted to Sample Primary Care Doctors Psy chiatric Psy ch. Bed Serv ice

Figure 1: Incidence of ‘mental illness’

Functional Psychosis Depression All Phobias including OCD and Panic Disorder Generalised Anxiety Disorder Drug and/or Alcohol Dependence Mixed Anxiety and Depressive Disorder

Figure 2: Prevalence rates – OPCS household survey.

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___________________________________________________________ Figures 1 and 2, though based on data from the mid 1990s 48, are useful in illustrating the extent of ‘demand’ from the general public for the treatment of depression and anxiety in primary care medical services. The community sample in figure 1, based on OPCS 49, indicates that almost a third of the population regards themselves as having some form of mental distress, and that just under a quarter of the population seek medical assistance from their General Practitioner; the characteristics of mental distress is broken down in figure 2. Research suggests the information from these charts continue to be valid 50. Within primary care patients today with psycho-social distress represent 30% of all GP consultations and around 50% of all consecutive attendees at GP surgery 51. Further more; findings from Goldberg and Huxley’s earlier study 52 can be used for purely illustrative purposes, in demonstrating the extent to which self-diagnosed incidence of ‘mental illnesses’ are being expressed within primary care settings. Of importance is that of 250,000 patients presenting at GP surgeries annually approximately 150,000 cases, almost two thirds, do not have their illness ratified by the GP. Whilst GPs may recognise people’s distress it was not regarded as an illness. The majority of patients identified as depressed in primary care do not necessarily display signs of a formally defined mental illness. It has consequently been suggested that many are distressed rather than ill 53. Of course treating distress as mental illness in a primary care environment would constitute the medicalization of a normal human response to adverse life events. In a broader context more recent work has illustrated those patients who seek medical help are often not the sickest’ 54 and highlights the complex nature of illness behaviour. This does pose a number of questions relating to the diagnosis of depression and this has encouraged a number of further studies, considering aspects of the diagnostic process 55. Studies have explored GP’s perceptions and ability to detect psychological distress, patient’s views concerning their own health, and the relationship between diagnosis of depression at primary care level and inappropriate referral letters to psychiatric services. GPs respond with arguments about a nonappreciation of the context of pressure on diagnosis in the primary care setting 56. It is consequently worth exploring how GPs may be ‘inappropriately’ accepting offers of illness from the public and thus contributing to the medicalization of emotions. 5.

Role of General Practitioners

The extent of the demands made upon GPs that may arise from drives for emotional exchange has been mentioned and is evident in Figure 1. There is probably nowhere in the healthcare system where the interaction between personal emotional narrative and illness is more

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___________________________________________________________ strikingly displayed than within the primary care setting. Understanding this narrative through the interaction of illness behaviour and social action, alongside an appreciation of the emotional scarcity characterising society at large, provides a basis to suggest that what is presented to the general practitioner and their role within that falls outside of any traditional medical encounter. The notion of patients actually seeking the medicalization of personal problems has often been constructed by GPs in terms of a social aetiology. Patients presenting at GPs surgeries were derived from their knowledge that there is an illness called depression that it seems widespread, and doctors are there to treat it. Chew-Graham claimed: “Patients actually a lot of the time want a medical answer. They want a quick fix; they want to have something done. 57” It is to what that they should seek a quick fix for? If as James 58 suggest we are ‘miserable’ despite the promises Capitalism makes, then is the level of unhappiness at the social and emotional interface where deficiencies of wider society in creating and responding to this unhappiness are being expressed elsewhere? One of the benefits to patients of adopting expert knowledge systems is that they are best able to communicate with professionals. Work by Abbott has highlighted the ways in which people `preprofessionalise’ their thinking and language in the lead up to an encounter with a professional. They do this in order to present their case in the best possible light 59. Equally, of course, clinical tasks are embedded in the social process of authoring the accounts of patient’s symptoms to fit medical categories. In terms of ideology, patients want to know (and want others to know) that it is the illness (depression) that is at fault rather than them and that they are undertaking a course of treatment. This is a view reinforced by David Heally in his work on entitled ‘The Antidepressant Era’ 60. GPs in an initial consultation typically have only between 7 and 10 minutes to make a diagnosis and decide upon a treatment. The officially recognised diagnostic criteria for depression are contained in ISD 10 and DSM 4. These are weighty tomes which are not of much use in the context of a 10 minute consultation. There is also evidence that they are not used in the context of a 45 minute psychiatric assessment 61. Given the high levels of demand upon the GPs to treat psycho-social distress and the work and diagnostic context it seems almost inevitable that some degree of medicalization will occur at this level, despite the fact that GPs are clearly attempting to reduce the numbers of people they treat and engaging in their traditional gate keeping role. Two key findings from a recent study 62 suggest that the following are important in informing diagnosis: Firstly that diagnosis both accommodates and acknowledges the reality of existential despair that is framed as a key component of depression by patients. GPs may see

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___________________________________________________________ someone living in deprived circumstances and whilst they can do little about the context, one way to relieve the misery might be by prescribing antidepressants. Secondly, conceptions of health and illness reflect the values of capitalism and individualism, in that they are imbued with notions of self-discipline, self-denial, self-control and willpower. Notions of dependency in Western societies are regarded as negative. Having the strength to overcome problems reflects more general social norms and values found in capitalist societies. 6.

The Medicalization of Daily Living

Alongside the response from GPs, it is worth exploring the notion that the population may indeed be self medicalizing their problems and why this may be the case. A starting point for much of medical sociology is that illness is a form of deviance. As such notions about illness have to be related to some concept of normal `health’. This norm is socially constructed and will vary from culture to culture and over historical time 63. It could be argued that in Western society misery is being seen not only as deviant to social norms, but also a part of the preserve of medicine. We would argue that high rates of medicalization are actually indicative of systemic problems in western society. Whilst acknowledgement is made to the biological basis of the illness, the focus is upon milder forms of ‘depression’, otherwise referred to as ‘subthreshold’ disorders, and the assertion that help seeking behaviour is based upon individual responses to both the demands contemporary society places upon being an ‘individual’ the lack of social cohesion which exists. Indeed, late modernity has been associated with the harsh effects of individuality 64, under which circumstances life can appear to be burdensome and increasing levels of anxiety and stress prevail. To be ‘ordinary’ today proves to be a task in itself. People’s endeavour at obtaining meaning and worth today, which at one point would have been embedded within the very fabric of community life, may be represented within the pursuit of an illness diagnosis, where emotions are translated into action. On one level modern society has contributed towards liberating the individual from the organisation and dependency of pre-modern culture, but where the notion of community for example no longer exists. TS Eliot wrote, “What life has you if not life together? There is no life that is not in community…” 65. Individuals were once immersed firmly within small villages and friendships and the organisational forms then ‘occupied the whole person they did not only serve an objectively determined purpose, but were rather a form of unification.’ 66 Such organisation today is unusual within society. The individual’s character in not solely

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___________________________________________________________ embedded within the social fabric of one village or one group, rather it is part of varying circles of people where the individual takes on a number of inter-changeable roles. In contrast to pre-modern times, the individual today claims his/her social position through a multiplicity of functions within different groups and wider society. Traditional community once provided a number of support mechanisms to both emotional and social need. The relevance of the traditional anchors and support mechanisms of community – the family, neighbourhood and the church have been sharply eroded over the last 50 years in the UK. In its place is a consumer culture centred on the fulfilment of individual desires and where the individual has become the core unit of social consumption. The offer of illness may act as a response to re-positioning the self within a framework that gives a sense of meaning to the individual. This is characteristic of modern western society in which one of the vehicles for this change is the consumer culture. Social Consumption it is argued 67 is bound up with notions of what it is to be a fully developed human being, morally and spiritually. Maslow’s argument is used here to makes illustrate that human motivation across all societies and at all times is organized in a hierarchical structure of need to focus upon the value of consumer society. The need for knowledge and understanding and our aesthetic need for beauty - consumerism is a spent force. As for self-actualization, the fulfilment of our potential as human beings, consumerism is its antithesis. “Consumption delivers only pleasure, not happiness” 68. However, happiness, not pleasure, is the final goal of human life, and only through living as much for others as for oneself can people really be happy and reach their full potential (which is self-actualisation). Contemporary consumer society certainly seems to possess a diminished capacity to answer the question of ‘who we are’. Fukuyama argued that the quest for identity, recognition and happiness is “one of the chief motors of the entire human historical process” 69. In a competitive individualistic society, the “appearance of being socially denigrated or humiliated endangers the identity of human beings, just as infection with disease endangers their physical life” 70. This is leading to demands for ‘the right to be esteemed and recognised’, particularly for those feeling vulnerable in a competitive individualistic society. The rise of ‘therapeutic demand’ arising from a breakdown of solidarity and community is becoming manifest in a number of areas. As Furedi points out, “at a time of existential insecurity, a medical diagnosis at least has the virtue of definition.” 71 A disease both explains an individual’s behaviour and helps to ratify a sense of identity. In other words, the medicalization of everyday life allows individuals to make sense of their predicament and gain moral sympathy. It could also be argued to represent a socially sanctioned claim for recognition. As a

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___________________________________________________________ consequence there is a demand from people to expand diagnosis in medicine to recognise their situation, and ultimately their distress, which at one time would have been dealt with through support mechanisms found within communities (e.g. ME, Gulf War Syndrome, Post Traumatic Stress Disorder, RSI etc). In doing this people are `relieved of responsibility' for their behaviour as they gain recognition for their situation. Patients today may be looking for a ‘quick fix’ or a magic pill that will make them happy. This is also the background to the massive growth of the ‘psy-industries’ of counselling and psychotherapy. People are ‘buying into’ such services in search of happiness and self-fulfilment, but such services can only reconcile people to ‘what is’ and in doing so also renders self-identity dependent upon those professionals. 7.

In Conclusion

The role of emotions in relation to human action is extremely complex. The politics of recognition linked with the increasing medical understanding of lay people has led to the medicalization of everyday life. This we can attribute to a number of areas, but would appear to lean towards socio-cultural factors present within today’s society, as some people search for recognition in a society which they think does not care about them; they seek diagnosis and therapy as a means to social affirmation. An important part of this debate is to understand why so many people feel distressed and emotional to the extent they do. Whilst development of self and subjectivities over time is in part responsive to the changing face of emotions, there is a degree of social causation driving this; if we look at the changing pace of life, and changing nature of society, the difficult in maintaining a home-work life split, and changes within communication for example. It transpires therefore that when considering the role of emotions within the presentation of unhappiness, there is both room to consider ‘individual and institution making’ 72. That is, to consider how: ….the social realm itself is embodied: a notion which can give form to the relationship between the social structural milieu in which humans live, their subjective experience, and the flesh through which that existence is lived 73 In the daily sphere of general practice, all of these factors lead to increasing demands upon primary care practitioners, especially GPs. The traditional power imbalance between GPs and patients would seem to have undergone some change. It no longer seems to be GPs medicalizing

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___________________________________________________________ problems but rather an attempt to manage demand. It could be argued that they could be more efficient in ‘sifting out’ the social from the medical. However, this must be seen in the context of the pressures of work, the difficulty of making diagnosis of a complex condition in a very short time frame, and the marketing of anti-depressants which are increasingly targeted at milder and milder forms of ‘depression’ for profitability. The demands on GPs result from individual solutions to systemic problems. And it is consequently at the level of social change that solution to demands should lie. Ultimately, whilst consideration can be given to how emotional contexts translate into demand for services, wider questions relating to whether we should be responding to this, and indeed if we should be responsible for it are equally important to address.

Notes 1.

P. Conrad “Medicalisation, Generticas, and Human Problems,” in Handbook of Medical Sociology 5th Edition, ed. C.E. Bird, P. Conrad & A.M. Fremont, (Prentice Hall, 2000), 322-333. 2. J. Pitts, ed., International Encyclopaedia of Social Sciences. Vol. 14 (New York: Macmillan, 1968) s.v. “Social Control: the Concept.” 3. I. Illch, Medical Nemesis, the Exploration of Health. London: Penguin, 1976. 4. A. Oakley, Women Confined, (Oxford: Martin Robertson & Company, 1980), 18. 5. E. Freidson, Profession of Medicine. (New York: Dodd, Mead, 1970); I. Zola, “Medicine as an institution of social control,” Sociological Review 20 (1972): 487-504; Illich, 1976; & Conrad, 2000. 6. G. Bendalow & S. Williams (Eds.) Emotions in Social Life. Critical Themes and Contemporary Issues, London: Routledge, 1998. 7. Zola, 1972 8. E. Friedson, Profession of Medicine: A Study of the Sociology of Applied Knowledge, (Chicago, Ill: University of Chicago Press, 1988), 71-84. 9. A. Peterson & R. Bunton R. (eds.) Foucault: Health and Illness. London: Routledge, 1997, 96. 10. T. Szasz, Ideology and Insanity: Essays on the Psychiatric Dehumanisation of Man. (Garden City, NY: Doubleday, 1970); G. Rosen, “The Evolution of Social Medicine,” in Handbook of Medical Sociology ed. Howard E. Freeman, Sol Levine & Leo Reeder (Englewood Cliffs, New Jersey, Prentice Hall, 1972), 30-60. 11. N. Rose, “Psychiatry: the discipline of mental health,” in The Power of Psychiatry, ed. P. Miller & N. Rose. (Oxford: Polity Press), 43-84.

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___________________________________________________________ 12.

Ibid, 49 Peterson & Bunton, 1997 14. Illich, 1976 15. R.C. Fox, “The Medicalization and Demedicalization of American Society,” in The Sociology of Health and Illness: Critical Perspectives, ed. P. Conrad (New York: St. Martins Press, 1997), 415-419. 16. Peterson & Bunton, 1997, 96 17. Z. Bauman, Modernity and Ambivalence. Cambridge: Polity Press, 1991. 18. W.W. Eaton, The Sociology of Mental Disorders. Westport CT: Praeger, 2001., 28 19. M. Verweij, “Medicalization as a moral problem for preventative medicine,” Bioethics 13.2 (1999): 89-113. 20. S. Fineman, (ed.) Emotion in Organisations, (London: Sage, 1993), 20. 21. P.S. Baker, W.C. Yoels, & J.M. Clair, “Emotional Expression during medical encounters: social dis-ease and the medical gaze,” in Health And The Sociology Of Emotions, ed. V. James & J. Gabe. (Oxford. Blackwell, Publishing, 1996), 173. 22. S. Williams, “Reason, emotion and embodiment: is ‘mental’ health a contradiction in terms?” in Rethinking the Sociology of Mental Health, ed. J. Bshfielf. (Oxford: Blackwell Publishers, 2001), 17-39., 22 23. E. Blackwell, [1902] “Erroneous method of medical education,” in Essays in Medical Sociology, ed. E. Blackwell (New York: Arno Press, 1972); Engles, G. The need for a new medical model: a challenge for biomedical education, Science 196 (1977):535-44. 24. O. James, Britain on the Couch: Why We’re Unhappier than We Were in the 1950s – Despite Being Richer. London: Arrow, 1998. 25. Ibid 26. R. Layard, “Happiness and Public Policy,” LSE Health and Social Care Discussion Paper Number 14, (London: LSE Health and Social Care, 2005), 7. 27. Ibid, 8 28. James, 1998 29. Williams, 2001, 17 30. cf Satre 1971 [1939] 31. Williams, 2001 32. N. Crossley, “Emotions and Communicative Action,” in Emotions in Social Life: Critical Themes and Contemporary Issues ed. G. Bendalow & S.J. Williams (London: Routledge, 1988), 16-38. 13.

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33.

In the UK GPs are required to have a basic medical qualification, which consists of five years undergraduate study combining academic work and experience in both hospitals and in the community. Successful students qualify as a ‘bachelor of medicine’ and ‘bachelor of surgery’. To practise medicine, all doctors must be registered with the General Medical Council (GMC). Doctors wishing to become GPs undertake a minimum of a further three years training, the time divided between work in hospital and in general practice. There are additional qualifications offered by medical Royal Colleges and many GPs are members of the Royal College of General Practitioners, a network of around 22,000 doctors who are committed to improving patient care, developing their own skills and developing general practice. In response to the changes in healthcare delivery the NHS Plan for England encouraged the development of general practitioners with specialist interest in a limited range of specialties, know as GPSIs. Whilst GPs are said to be experts in family medicine, these are GPs who have developed enhanced skills so as to provide a variety of extended services that have traditionally been provided in secondary care, in a primary or intermediate tier care setting; for example there are GPs with a specialist interest in mental health. After appropriate training GPSIs will be able to take referrals from other general practitioners, although this occurs to some degree already. However, GPSIs will be able to see patients from other practices within a primary care organisation, with the agreement of secondary care specialists. A local consultation team will be involved in these developments, and GPSI and local consultants will be essential in planning local health care. 34. Panorama, The Tranquilliser Trap, 13 May 2001 BBC1 35. M. Lyon, “C. Wright Mills meets Prozac: the relevance of ‘social emotion’ to the sociology of health and illness” in Health and the Sociology of Emotions, ed. V. James & J. Gabe. (Oxford: Blackwell , 1996), 57. 36. Lyon, 1996 37. Conrad, 2000 38. Zola, 1972 39. H. Middleton, and I. Shaw, “Distinguishing Mental Illness in Primary Care,” British Medical Journal 320 (2000): 320-321. 40. M. Riley, “Understanding Depression” Nursing Times 94 (1998): 26. 41. Ibid 42. R.P. Bentall, “A proposal to classify happiness as a psychiatric disorder,” Journal of Medical Ethics, 18 (1992): 94. 43. Conrad, 2000; 323

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___________________________________________________________ 44.

I. Zola, “Medicine as an Institution of Social Control,” in The Sociology of Health and Illness: Critical Perspectives, ed. P. Conrad (New York, St. Martins Press, 1997), 404-414. 45. M. Tausig, J. Michello & S. Subed, A Sociology of Mental Illness (USA :Prentice Hall, 1999), 139. 46. R.J. Orner, A.N. Siriwardena, & J.V. Dyas, “Anxiety and depression: a model for assessment and therapy in primary care,” Primary Care Mental Health, 2 (2004): 58. 47. Ibid, 57 48. D. Goldberg & P. Huxley, Common Mental Disorders. London: Routledge, 1992. 49. H. Meltzer, B. Gill, M. Pettigrew, & K. Hinds. The prevelance of psychiatric morbidity amongst adults living in private households. London: HMSO, 1995. 50. Middleton & Shaw, 2000 51. D. Kessler, K. Lloyd, G. Lewis, & D. Pereira Gray, “Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care,” BMJ 318(1999): 436-439. 52. Goldberg & Huxley, 1992 53. I. Shaw & H. Middleton “Recognising Depression in Primary Care,” The Journal of Primary Care Mental Health 5 (2001):2. 54. J. Gabe; M. Bury; & M.A. Elston, Key Concepts in Medical Sociology, London: Sage, 2004. 55. C.A. Chew-Graham, C.R. May, H. Cole & S. Hedley, “The burden of depression in primary care: a qualitative investigation of general practitioners’ constructs of depressed people in inner city,” Primary Care Psychiatry 6 (2002):4.; A. Howe, “‘I know what to do, but it’s not possible to do it’ – general practitioners’ perceptions of their ability to detect psychological distress,” Family Practice, 13:2 (1996): 127–132. 56. Shaw & Middleton, 2001; Chew-Graham, May, Cole & Hedley, 2002 57. Chew-Graham, May, Cole & Hedley , 2002 58. James, 1998 59. A. Abbot, The System of professions: An essay on the division of expert labour, Chicago, Chicago University press, 1998. 60. D. Healy, The Anti-Depressant Era. Cambridge (Mass): Harvard University Press, 1997. 61. Middleton, 2002 62. I. Shaw, “How Lay are Lay Beliefs?” Health 6.3 (2002): 287-299. 63. D. Pilgrim & R. Bental, “The Medicalisation of Misery: A critical realist analysis of the concept of depression,” Journal of Metal Health 8.3 (1999): 261-271. 64. U. Beck, Risk Society. London: Sage, 1992.

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___________________________________________________________ 65.

T.S. Eliot, “Choruses from `The Rock, (1934)” in Collected Poems 1909-1962, (USA: TS Elliot 1963), 145-160. 66. G. Simmel, Soziologie. Leipzig: Duncker und Humblot, 1908.; 419. 67. I. Shaw & A. Aldridge, “Consumerism, unhappiness and the role of medicine in society,” Leaves; the magazine of the Southwell Minster Community, August 2002, 9-10. 68. Ibid, 10 69. F. Fukuyama, “The Great Disruption: Human nature and the reconstitution of social order.” New York: Touchstone, 2000. 70. A. Honneth, The Struggle for Recognition: The moral grammar of social conflicts. Cambridge: Polity Press, 1995. 71. F. Furedi, “The Institutionalisation of Recognition – Evaluating the Moral Stalemate,” paper presented to DMAP Conference, University of Cardiff, 4-6th April 2002. 72. T.J. Csordas (ed.), Embodiment and Experience: the Existential Ground of Culture and S,elf (Cambridge: University Press, 1994).; M. Lyon & M. Barbalet, “Society's body: emotion and the “somatization” of social theory,” in Embodiment and Experience: The Existential Ground of Culture and Self, ed. by T. Csordas. Cambridge: Cambridge University Press, 1994 73. Lyon, 1996; 69

Authors Louise Woodward Research Development Lead & Medical Sociologist Nottinghamshire Healthcare NHS Trust Nottingham NG3 6AA Professor Ian Shaw Centre for Medical Sociology and Health policy School of Sociology and Social Policy University of Nottingham Nottingham NG7 1JD

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Nervios: Lessons from Cuba’s Oriente Traci Potterf Abstract Nervios [nerves], a condition primarily associated with depression, stress and anxiety, is one of the most common health complaints among Cubans. Study participants reported that internal and external political pressures, economic struggle, interpersonal strife, envidia [envy] and spiritual disturbances not only compose many of the root causes of nervios, but also shape coping mechanisms. Based on a twelve month ethnographic research project in Baracoa, Cuba, this case study examines people’s perceptions of how political economic and sociocultural factors combine to produce nervios and to influence their struggles to overcome it. Based on people’s day-to-day struggles for emotional well-being, my findings offer insight into the ways in which particular policies, beliefs and practices, on national and international scales, can both undermine and facilitate mental health. [Cuba, medical anthropology, mental health, “nerves”] 1.

Living with Nervios en Baracoa: Alma and Eucevio

Whenever I visited Alma, age 75, she complained she was suffering from nervios, or nerves. Trembling, pacing, worrying, mumbling, refusing food, and wringing her hands, she had not slept more than a few minutes at a time in days. Her family said she had been having trouble for over twenty years, at which point she more or less stopped practicing the Afro-Cuban religion of Santería, other than to attend to personal matters, family and close friends. When asked what makes her “nervous,” she explained that she is worried about her grandchildren’s problems, particularly regarding health and her disapproval of the people with whom they associate. She also feared that housing authorities would discover the family’s black market tomato puree business, and that officials inspecting for mosquitoes would defile her altar by touching the glasses of water she has set out for the saints, as part of her petition that they protect her family and resolve their most salient concerns. Alma believes in staying busy “for her nerves.” “I’m strong! I don’t let them dominate me.” She never leaves her house, but she sits for a few minutes a day in a chair she pulls into her small back patio, taking in some sun and “catching a little fresh air.” “It’s good for my nerves,” she explains. Her family medicates her with sedatives that she says make her feel worse in the long run. She prefers what Cubans call medicina verde [literally, “green medicine”] and prayer. 1 Occasionally, her grandson

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___________________________________________________________ brings her herbs such as tilo and purple basil to prepare in an infusion. Her granddaughter also gives her chamomile tea and valerian that her Canadian boyfriend brings when he visits; however, Alma only uses them when she feels particularly bad, because she does not want to waste her limited supply. Eucevio, age 38, considers himself “un tipo nervioso” [a nervous type]. “I suffer from nerves - everyone in my family suffers from nerves.” His nervousness came to a head while imprisoned for belonging to a group called Youth for Democracy. Once released, officials regularly watched and interrogated him. Continued surveillance to this day creates a great amount of stress that contributes to his nervous symptoms which are already agitated by day-to-day obstacles such as searching for enough food, procuring needed household items and trying to do “negocios,” [slang for black market “business”] without getting caught. He applied for admission into the United States as a political refugee, but the embassy denied his case. This, in combination with his daughter’s fragile health and his inability to provide for her heightened his chronic nervios, which manifests itself in the form of depression, withdrawal, trembling, high blood pressure, nightmares and interrupted sleep. Acute episodes have even led to angry public outbursts, which are highly uncharacteristic of his usually docile, gentle demeanour. He usually copes by smoking a lot of cigarettes, drinking rum, listening to romantic music, watching television or videos, going dancing with his friends, consulting with his padrino, or godfather of Santería, and sitting on the sea wall, looking out over the ocean. The family psychiatrist prescribed diazepam (commonly known as Valium) for him, but he does not take it on a regular basis - only when he feels he needs it. He says that not everybody can take this medication because it often makes you feel worse the next day, but affirms that it works for him when he really needs it. Alma and Eucevio’s scenarios were not unusual. I soon discovered nervios to be one of the most commonly expressed health complaints throughout my twelve months of research in Baracoa, a coastal tourist town in Cuba’s Oriente, or easternmost region. 2 The term is so pervasive and accepted in Cuba that even health practitioners regularly use it. According to both doctors and patients I interviewed, there is significant overlap between nervios and what conventional medicine describes as depression, stress and anxiety. However, in everyday application Cubans may also use “nervios” as a catch-all term to refer to a wide array of mental and spiritual disturbances, including schizophrenia, bipolar disorder, hypochondria and even perturbations provoked by the deceased, saints or orixas (the deities of Santería).

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___________________________________________________________ Those I spoke to emphasized “nervios” as a very real and painful, simultaneously physiological and emotional, condition. According to my observations, nervios in Cuba are manifest as varying combinations of agitation, catharsis, withdrawal and physical illness. Symptoms are diverse. Some include insomnia, nightmares, trembling, tachycardia, anorexia, obesity, high blood pressure, crying, screaming, pacing, nervous ticks, nagging, obsessive worrying, disorientation, withdrawal, repetitive compulsive behaviours, physical aggression, psychosomatic paralysis and other forms of stress-induced illness. Traditionally classified within the social sciences as a culturebound syndrome, more recent, comparative perspectives depict “nerves” as a widespread—nearly universal—phenomenon that varies in interpretation and expression from one population or socio-cultural context to the next. 3 Studies of “nerves” around the world have described it as an idiom or metaphor for embodied distress, worry, powerlessness, repression, deprivation, grief and fear. 4 There is no single universal definition of “nerves.” In their research on nervos in Brazil, Nancy Sheper-Hughes characterizes it as “polysemic” in nature while Linda Rebhun describes it as, “a very broad term.” 5 The meaning of the term nervios in Cuba, as anywhere else, is best captured in the contexts in which it is lived and with which it is contended. 2.

The Root Causes of Nervios in Baracoa

One man who suffers from nervios explains, “We Cubans are loaded down with a lot of things - a lot of preoccupations. They all build up and anything makes you lose your head. You stay locked in a vicious circle and feel like you don’t have an escape. Something provokes you and you explode.” Cubans I have spoken to do not generally stigmatize nervios, 6 but rather see it as a natural response to stress that manifests itself in a variety of emotional, spiritual, physiological and behavioral patterns. There was general agreement among Baracoeses I spoke to that a given person may tend to be more of a tipo nervioso [nervous type] than others, as in the case of Eucevio. The notion that nervios runs in families was also common. Education and public health initiatives have exposed Cubans to biomedical etiologies for mental illness, such as biochemical imbalance and genetic predisposition. However, if you ask most people why they suffer from nervios, they will refer to an accumulation of political, economic, interpersonal, personal and spiritual triggers.

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___________________________________________________________ A. Historical, Political and Economic Influences There is a definite interplay between historical, political economic forces and personal experiences of nervios. Here I will provide an overview of relevant Cuban history, from the time of the 1959 Revolution to the present. In doing so, I will outline many of the chief factors that have seriously affected Cuban’s day-to-day quality of life and, thus, their emotional well-being. Conditions for many Cubans, particularly blacks, women and the poor, are said to have improved in the first decades following the triumph of the Revolution. Thanks to the support of the Soviet Union, most people could survive on their salaries. Furthermore, a considerable percentage of the state budget was allocated to state sponsored health care. Thus, availability of medical services increased, extending into even the most isolated populations. As average life expectancy and infant mortality statistics reached those of “first world” countries, Cuban state sponsored health care gained international acclaim. 7 Up until Castro took power, Cuba was devoid of any semblance of competent or humane mental health care. Over a period of several years, the Revolutionary government trained new psychiatrists, nurses and social workers as well as built psychiatric hospitals. It also promoted tolerance, compassion and respect toward the mentally ill, who had previously been abandoned, abused or jailed. 8 Cuba attained these achievements in spite of the U.S. Embargo. A myriad of new and more stifling laws, such as the 1992 Cuban Democracy Act, the 1996 Helms Burton Act and the increased restrictions of 2004, have compounded economic and political tensions as well as have handicapped public health efforts. 9 By prohibiting trade with Cuba and effectively pressuring other countries to follow suite, the embargo has driven up food and health care costs as well as has deprived Cubans of access to U.S. patented or manufactured products, many of which are unavailable by any other means. These include important medications as well as replacement parts necessary to repair existing hospital equipment and water treatment facilities. Furthermore, people I interviewed pointed out that 2004 laws impeding remittances and family visits from the United States constitute as much an emotional as an economic burden. While the embargo crippled the Cuban economy, Castro’s government managed to endure with the support of the Soviet Union. During this time, agriculture was dedicated to cash crop production, and most of the population’s food supply was imported from the Soviets. The U.S.S.R. had also become Cuba’s petroleum source. Unfortunately, Cuba put all its eggs in one basket, so that when the Soviet Union collapsed, Cuba nearly did as well. In the early 1990’s Cubans plummeted into a severe economic crisis, known as the Período Especial, or “Special

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___________________________________________________________ Period.” The situation left them with no reliable market for their sugar and tobacco and little arable land allocated for food production. This resulted in severe food, fuel and supply shortages. The peso soon became practically worthless as prices skyrocketed. Malnutrition was a major problem, leading to an optical and peripheral neuropathy epidemic. 10 Lack of petroleum meant no electricity, cooking fuel, potable water or trucks to transport what little food and supplies there were. Personal and household goods were nearly impossible to obtain. Medical, sanitation and industrial supplies were short; equipment could not be repaired. The government was forced to close factories and water sanitation plants could not be maintained. Cubans report that their own government’s strategies to maintain power have compounded the effects of external threats and economic crisis, resulting in greater feelings of powerlessness, stress and anxiety. The government’s response to U.S. hostilities and internal economic crisis has consistently been to impart a fervent rhetoric of fear and relentless government control. This is manifested by both media propaganda and a network of block captains and hidden informants that penetrates even the furthest reaches of the island to weed out anti-government activity, black market business and any other economic or ideological endeavour deemed “anti-revolutionary” or “anti-social.” People must live with the knowledge that they are being watched, at times by known officials and often by unknown informants—perhaps even a friend or relative. Based on my observations and interviews, it does not take much to be called in for questioning. Threats of fines, property confiscation and even imprisonment are very real, particularly in a small town where word gets around quickly. Everyone I knew had, either directly or indirectly, experienced a brush with the authorities. With the onset of the Special Period, the black market exploded. People risked going to prison to obtain dollars to buy food and clothing at exorbitant prices. Even now, wages for full-time official employment remain so low that nearly everyone - even the most devout of revolutionaries - must live off the black market and remittances from abroad. This essentially means that one must break the law to survive, creating the constant need to sneak around and lie - to watch over one’s shoulder and calculate the amount of “riesgo” [risk] involved in any given transaction or disclosure. 11 People I interviewed frequently mentioned preoccupations with “riesgo” in connection with daily stress levels. Cubans disagree as to whether the Special Period has ended or merely waned. Tourism and biotech, along with legalization of the dollar and limited privatization, have significantly boosted the economy. Agricultural reforms have made food more available and have diversified the diet. 12 Nevertheless, Cubans continue to live with hunger, supply and

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___________________________________________________________ fuel shortages, under-employment, disproportionately low incomes, strict social control, distrust, lack of privacy and solitude. The continued U.S. embargo and increasing tightening of U.S. restrictions continue to impact the Cuban economy and to provoke extreme tension in both political and personal realms. In the last few years there has also been fear that political instability in Venezuela, Cuba’s political ally and primary source of affordable petroleum, could further destabilize the Cuban economy, possibly creating conditions reminiscent of the height of the Special Period—a thought that is too much for most anyone’s “nerves” to bear. B. Baracoa During the Special Period and Today The height of the Special Period was an extremely traumatic time whose reverberations are still felt today. I am told that many people “got sick from nerves” as a result. In Havana during the Special Period people were reduced to eating bread and drinking sugar water to survive. Ask anyone from Baracoa and he or she will tell you about how people ate boiled banana peels. “Bread was for the rich - the people in big cities like Santiago and La Habana,” explained Fernando, a gentleman in his sixties who now sports a round belly. “We didn’t have bread - there was no flour.” Another man reports that he was lucky enough to have had a cousin who grew tomatoes, which the family would stew with banana peals to make them more palatable. Baracoa may not have had flour, but its rural location was an advantage to some degree. Different family members would go out into the countryside to bring whatever they could find. Bananas and coconuts were selling at premiums. Still, people reported going days without eating – sometimes three or four at a time. Many still have pictures from those times. People were so thin and gaunt that I often did not recognize pictures of people I know very well, who have become rather filled-out. Nevertheless, to this day, people in Baracoa report that they eat more or less well for the first 15 days of the month, then start skipping meals...lunch today no dinner, dinner the next day, no lunch...next to nothing the next day, etc. This does not apply to every family, as some enjoy higher incomes from tourism or support from outside the country. Nevertheless, I frequently observed serious food rationing and meal skipping. People would often assuage hunger by consuming bread with lard or margarine, saltines with mayonnaise, coffee, sweet drinks and cigarettes. People I interviewed did not hesitate to attribute their nervios, in great part, to the struggle to put food on the table. C. Politics and Social Relations: Who Can You Trust? When I first arrived in Baracoa, I thought it exaggerated that so many people complained, “You can’t trust anyone” and “Here I don’t have (real) friends.” It was not long before I understood what they meant. At

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___________________________________________________________ an interpersonal level, the stress and frustration of constant cycles of scarcity and tight social control have led to increasing distrust, conflict, corruption, envidia [envy], suspicions of witchcraft and, ultimately, nervios. As I was sitting in Odalis’ living room, she emerged from the kitchen with a pan full of ice and set it on the floor behind the door. “What is that for?” I asked. “Para enfriar lo malo.” [loosely translated, “To chill the evil.”] After further inquiry, it turns out that she and her mother were experiencing frequent “clashes with people” that were setting off both their nervios. She explained, Lately we have had to deal with many people who come in and out of our house. They’re always looking over your shoulder to see what you have and don’t have, what you do and don’t do - they have envidia and they can hurt you. If you have something someone else doesn’t have, they envy what you have. If something bad happens to you, they pretend they feel bad for you, but in reality, they don’t want to see you happy, especially not happier than them. It’s like that here. We have to live with that. She later confided that her family had experienced several incidents in which supposed friends betrayed them by telling officials about anything from a subversive movie they watched to their family’s black market activities. Similar complaints are widespread among friends, family, spouses, romantic partners and neighbours. You never know who is a gossip or a snitch, who is envious of you or who might be using you for socio-economic leverage. Ironically, people must co-operate and come together as a community to survive; however, because you have to be careful, never trusting one hundred percent, the result is often feelings of emotional isolation. D. “He Studied Too Much” Another perceived cause of nervios merits attention. In Baracoa, Havana and Santiago I heard of several cases in which an intelligent person “studied too much,” then “got sick from nerves.” The government promotes education and “culturing” oneself, but the popular concept that too much can drive you crazy is pervasive. One interesting example is the case of Fernando. Though officially diagnosed with schizophrenia, the community knows him, not as a schizophrenic, but rather as someone who is sick from “nerves” because he studied too much. Even he believes that the sources of this illness are his studies and societal stress. He is

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___________________________________________________________ convinced that if he could only leave Cuba, his mental illness would go away. E. Higher Authorities Cuba has its share of atheists and agnostics. For many others, social, political and economic pressures are enmeshed in a much larger reality whose authorities are far more powerful than the weightiest of world leaders, local officials, economic fluctuations and gossipy neighbours. This is the realm of spirituality, be it Christianity, AfroCuban religions, spiritism or some other brand of mysticism. People often cite upsets in this dimension as a source of nervios. For example, a spiritist explained to me that spirits of people who loved us very much in life sometimes follow us and watch over us, but that although they have loving intentions, they can cause perturbaciones [perturbations] and trastornos mentales [mental disturbances], “…especially in our sleep and at night because we sense them and it scares us.” Practitioners of Afro-Cuban religions such as Santería and Regla de Palo will attribute mental distress, disturbing life events and bad luck to factors such as another person’s envidia [envy], an inadvertently inflicted mal de ojo [evil eye], or, more rarely, an act of hechicería [a curse]. Mental disturbance might also originate from a displeased orixa, saint or muerto [deceased person] whose good graces usually require rituals, offerings and prayer. Those who do not ascribe to beliefs in the supernatural will often refer to themselves as “realistas” [“realists”] while those who do will call themselves “creyentes” [“believers”]. Disputes between “realists” and “believers” over the etiology of “nerves” were not uncommon, even within families. For example, Luisa, an eighty-seven year old devout Catholic, attributes her daughter’s suicide hanging to a curse put upon her by a woman because of jealousy over a man. Luisa’s seventy-nine year old brother, a self-proclaimed “realist,” adamantly protests, “No, no one did anything to her - she was sick! People don’t get sick from witchcraft and curses.” Lowering his voice and peering directly into my eyes he inquires, “Do you know why?” Raising his voice in a crescendo, he announces, “Because witchcraft doesn’t exist! It simply doesn’t exist!” No matter, Luisa’s conviction that her daughter was a victim of violence is as real and natural as if someone had stabbed her or shot her. This infuriates and frustrates her brother to no end. F. Gender and Nerves Most studies of “nerves” as such focus on women, reasoning that “nerves” arise where women are oppressed and where “male” forms of venting, such as drinking and physical aggression are not deemed appropriate for females. 13 While there are studies that report men who suffer from “nerves,” 14 they are not representative of the predominant

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___________________________________________________________ view on gender and “nerves” in academia. While I did observe differences in expression of nerves between men and women, I found that men and women were both quite likely to suffer from nervios. In Cuba, women wield significant power and expressive freedom. Despite the undeniable presence of machísmo, 15 Cuba follows the Caribbean pattern of predominantly female-headed households. 16 Secondly, women and men are highly communicative and openly share health issues with each other. This, combined with the fact that nervios is not highly stigmatized in Cuba, leaves men free to express “nerves”. What is more, both men and women are subject to the constraints of poverty and severe social control, not to mention the eyes of nosey, envious neighbours, and even the whims of deities and the deceased. For the most part, I found that one’s response to “nerves” depended more on individual traits than any other factor. However, there were observable expressive differences between men and women. Women I witnessed suffering from nervios tended to be quite vocal, even theatrical, and emphasized their suffering. As Linda Rebhun found in her study of Northeast Brazil, women also used their “nerves” to influence their family members and friends to take a particular side or to amend unwanted behaviours. 17 While some women reached varying degrees of physical and verbal hostility, men appeared more prone to physical aggression. They were also more likely to drink and hold in certain emotions. Many would withdraw and seethe quietly, then explode angrily once the pressure became too great. Even though they expressed themselves differently, these men asserted that they were suffering from nervios. Where ethnographers have concluded that men do not suffer from “nerves”, or at least suffer less than women do, I question the extent to which shame or stigma inhibits male expression of emotional vulnerability. In other words, do men suffer less from “nerves” or do they hide their “nerves,” perhaps concealing them or disguising them as anger? I also question characterizations of drinking and physical aggression as alternatives to and not manifestations of “nerves”. In Cuba drinking and physical release are considered a way to purge oneself or numb oneself. The fact that men express nervios somewhat differently by no means implies that they are less affected than women are. There are times when there is just too much to bear, and one’s body responds, regardless of gender. 3.

Struggles to Overcome Nervios

Many women and men I knew in Baracoa explained to me repeatedly that it is important to “dominate your nerves” so that your nerves “don’t dominate you.” For Cubans these days, that struggle is a

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___________________________________________________________ daily battle. It is also an eclectic, pluralistic and inventive battle. One man in his seventies astutely observed, “El Cubano se agarra por cualquier clavo caliente, pero no se deja caer” [“A Cuban will grab onto any hot nail, but won’t let himself fall”]. People in my study dealt with nervios by implementing a myriad of creative strategies. While they utilized state health care to an extent, they largely dealt with nerves via popular healers and self-medication. 18 A. State Sponsored Health Care My research reveals that, although the Cuban health system provides unlimited free access to care, it often does not address many of the underlying causes of nervios. Cuba’s extensive network of dedicated health practitioners is limited in terms of both time and resources. What is more, they cannot change deeply entrenched political, economic and social stressors. Their role is limited to facilitating the coping process. As in biomedical contexts worldwide, this usually means treating symptoms with pharmaceuticals (e.g. diazepam, chlordiazepoxide, meprobamate and chloral hydrate). In more severe cases, patients are hospitalized in larger cities such as Santiago de Cuba and Havana. Even where given the option of psychotherapy, for many patients, openly discussing socio-economic stressors such as scarcity, underemployment, social control and political persecution are feared to be associated with an “anti-revolutionary” attitude. Furthermore, the biomedical model does not address many of the social and spiritual dimensions people attribute to “nerves”. At the outset of the 1959 Revolution, the government all but prohibited “traditional” medicine. However, the Special Period, combined with international trends toward “natural” and “alternative” medicine, prompted the rapid development of state health care’s Medicina Natural y Tradicional (Natural and Traditional Medicine) program, which now composes a significant portion of medical treatment protocols. At present these modalities focus more on physiological than psychological and social aspect of illness. Nevertheless, medical practitioners are beginning to speak out against the overuse of pharmaceutical sedatives, pointing instead to “non-toxic” alternatives such as herbal remedies, acupuncture, exercise, meditation and flower essences. In fact, flower essences constitute an increasingly common alternative to psychotropic pharmaceuticals in larger cities such as Havana and Santiago de Cuba. Much like the rest of the state system, shortages of both information and materials impede access to these modalities outside of principal cities. Doctors report that people have been highly receptive to natural and traditional medicine, which is not surprising given their country’s cultural history of popular medicine that has long implemented plant, animal and mineral based remedies as well as medico-religious practices.

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___________________________________________________________ B. Popular Medicine My ethnography revealed that, while the state sector offers much desired pharmaceutical sedatives and hospitalization for severely afflicted patients, the popular sector constitutes the principal resource for Cubans confronted with nervios. In response to nervios, people employ varying combinations of self-medication and consultations with popular healers, implementing a wide variety of plant, behavioural and ritual modalities, many of which treat social and spiritual aspects of nervios not addressed by conventional medicine or the government. It is not uncommon for doctors and scientists to seek out popular healers for their own concerns and informally refer patients to santeros, spiritists and herbalists. Popular healers range from formally educated botánicos [herbalists] to practitioners of Spiritism and Afro-Cuban religions to simply what are known as “gente que sabe” [“people that know”], usually elders that have a don [gift from God] or who have passed along knowledge from one generation to the next. People suffering from nervios might seek plant, animal or mineral remedies from a secular herbalist or consult a practitioner of Santería or Spiritism who would, by means of a divinatory process, recommend an appropriate ritual and possibly an herbal component. These practitioners more often than not take into account spiritual as well as pharmacological properties of plants. A person might first consult an elder who “knows,” more often than not a neighbour, mother or grandmother. Similarly, the respected individual might practice divination and recommend a “natural” or “traditional” remedy, ranging from a given concoction to prayer or even a mini-ritual. Any of these people would be able to ascertain whether one’s nervios were provoked by socio-emotional stress or malevolence, such as envy, evil eye, bewitchment, a restless spirit or a discontented deity. While many such healers are trusted, increasing numbers are looked upon as charlatans and abusadores [“abusers”] who simply seek money and power. The latter often target tourists and relatively well-off Cubans, but may also deceive desperate poor individuals. In the case of Odalis, who was having trouble with neighbours and envy causing interpersonal strife and nervios, she consulted a Spiritist. When I went to see that woman, she started feeling bad. She had to apply alcohol all over her body and her hairs were standing on end. She said she felt a lot of evil - a lot of negativity - and started to mount the spirit she always mounts. 19 She ordered me, first, to get a bucket of water, fill it with alcohol and crushed ice and pour it in the corners of the house and under the beds and furniture. Afterwards, I had to make three crosses with alcohol on the floor in front of the door and set them on

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___________________________________________________________ fire. I did that yesterday. I also put the ice behind the door for the first time yesterday. I have to do it three times - yesterday, today and tomorrow. With a warm smile she adds, “One has to believe. If you don’t believe, it doesn’t work. You have to do it with feeling.” In Cuba, Religion and spirituality provide a sort of “way out”—a higher authority that offers solutions that mere humans can or will not. 20 In addition to consultations with state health practitioners and popular experts, so to say, Cubans commonly self-medicate for nervios. While many people’s medications are prescribed by a psychiatrist, others obtained sedatives much as they obtain anything else - through social networking and the black market. Most households have one or more of these medications on hand at all times. In addition to prescription sedatives, some people take Benadryl to be able to sleep at night. One problem with the prevalence of sedative consumption is that people commonly self-medicate with rum as a way to reduce stress. A pharmacist friend, Carolina, is alarmed at the rate at which people mix pills for “nervios” and alcohol. She comments, “Mixed together, they screw you up… They make you kind of go crazy.” Self-medication for nervios in Cuba reaches far beyond pill popping. Cubans will try a little of everything, whether obtained from the ground, the sea, state pharmacies or visitors from abroad. In managing their own experiences with “nerves,” most people resort to a wide array of solutions, from local plant remedies to homemade rituals and altars, to sugar water and walks on the beach. They are quick to implement both new and traditional strategies as well as to substitute or make do when necessary. More often than not, they combine multiple remedies and will even “inventar” [“invent”] new ones. 21 One of the most significant concepts associated with stress relief is that of “descarga,” literally unloading or discharging. Descarga is anything that rids one of nervous energy, has a relaxing effect, is comforting or allays symptoms. It may take the forms of spending time near the ocean, talking through problems, sports, dancing, joking, drinking, smoking, sex and excursions to the countryside. Public holidays, particularly los Carnavales [Carnival], are also seen as important outlets or sources of descarga to relieve large-scale stress and “falta de ánimo” [lack of enthusiasm]. People I interviewed considered descarga crucial for self-management of nervios. During my research, it soon became clear that expressive and performative manifestations of nervios constituted forms of descarga, as they allowed for the release of frustration, anger and despair. As medical anthropologist Nancy Scheper-Hughes found in her study of Brazilian sugar cane workers and shantytown residents, open expression of “nerves”

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___________________________________________________________ may provide a relatively safe response to political economic and sociocultural stressors, particularly in repressive contexts. 22 In Baracoa I observed incidents in which officials treated political criticisms expressed during an ataque de nervios [“nervous attack”] with greater leniency because the person was deemed sick, or out of their right mind. This also applied at times to drunken outbursts. 4.

Conclusion

Stymied by U.S. policies, events in the U.S.S.R. and Venezuela, strict government control, poverty, vigilant neighbours and spiritual disturbances, Cubans feel like they are under attack from all sides in their day-to-day struggle for survival. The resulting stress makes them sick. They call this anxiety and stress-induced illness “nervios.” Studies of nerves form part of an extensive body of research exploring the interplay of culture, political economy and phenomenology with emotional suffering and mental illness. 23 Ethnographic research in Baracoa revealed how people experience nervios as both an individual and a collective phenomenon, inextricably embedded in patterns of economic privation and government control as well as understandings of the spirit world, lifestyle and interpersonal dynamics. This case study reveals how particular policies and cultural patterns, both domestic and international, combine to shape somatic, emotional, intellectual and behavioural responses to life stressors, particularly those which threaten their most basic needs, such as food, medicine and personal liberty. My research also revealed the extent to which Cubans depend on the popular sector to address nervios. Although people commonly make use of free biomedical care to acquire pharmaceutical sedatives, for the most part they manage their nervios on their own, preferring selfmedication and popular healers to what state-sponsored mental health care can realistically offer. In other words, while help is available in theory, in practice Cubans are handling most aspects of nervios on their own. Whatever the modality, whether sedatives, herbs, spirits, descarga or mind over matter determination, the story of Baracoa’s struggle to overcome nervios is indeed one of suffering, but it is also one of creativity, openness to experimentation, determination and resilience. Beyond policy implications for Cuba, political economic and sociocultural aspects of mental illness are universal concerns. Social scientists, government officials and health practitioners alike stand to learn from Cuban people’s pursuit of emotional well-being amidst significant hardship.

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Notes 1

Medicina Verde is a popular catch-all term used to refer to a wide array of natural and traditional remedies. 2 I conducted research from August, 2002 to June, 2003 and from April to May, 2004. 3 See Kaja Finkler, Spiritualist Healers in Mexico (South Hadley: Praeger, Bergin and Gravey Publishers, 1985); Setha Low, “Culturally Interpreted Symptoms or Culture-Bound Syndromes: A Cross-Cultural Review of ‘Nerves,’” Social Science and Medicine Vol. 21, No. 2 (1985): 187-196; and Setha Low, “Health, Culture and the Nature of Nerves: A Critique,” Medical Anthropology Vol. 11, No. 1 (1989): 91-95. 4 See Dona L. Davis, and Setha M. Low, eds., Gender, Health, and Illness: The Case of Nerves. (New York: Hemisphere Publishing Corporation, 1989); Linda Green, “Fear as a Way of Life,” Cultural Anthropology. Vol. 9, No. 2 (1994): 227-256; Linda-Anne Rebhun, “Nerves and Emotional Play in Northeast Brazil,” Medical Anthropology Quarterly New Series, Vol. 7, No. 2 (1993): 131-151; Nancy Scheper-Hughes, Nancy. “Embodied Knowledge: Thinking with the Body in Critical Medical Anthropology.” In Assessing Cultural Anthropology, edited by Robert Borofsky, 229-242. New York: McGraw Hill, 1994; Nancy Scheper-Hughes, Death Without Weeping: The Violence of Everyday Life in Brazil. Berkeley, CA: University of California Press, 1992; and Anne C. Woodrick, “A Lifetime of Mourning: Grief Work among Yucatec Maya Women.” Ethos Vol. 23, No. 4, Coping with Bereavement (1995): 401-423. 5 See Scheper-Hughes 1992, page 169, and Rebhun 1993, page 138. 6 The only instances of overt stigma I noted were directed toward severely mentally ill individuals with histories of aggressive or violent behaviour. 7 See Julie M. Feinsilver, “Cuba as a ‘world medical power:’ the politics of symbolism.” Latin American Research Review Vol. 24, No. 2(1989): 1-34; Ross Danielson, Cuban Medicine. New Brunswick, N.J.: Transaction Books, 1979; and Theodore H. MacDonald, A Developmental Analysis of Cuba’s Health Care System Since 1959. Lewiston, Queenston and Lampeter: The Edwin Mellen Press, 1999. 8 See Danielson 1979, MacDonald 1999. Overall, there is a lack of indepth documentation of mental illness or mental health care in Cuba.

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See American Association for World Health. Denial of Food and Medicine: The Impact of the U.S. Embargo on Health and Nutrition in Cuba. Washington, DC, 1997; Kamran Nayeri, “The Cuban health care system and factors currently undermining it,” Journal of Community Health Vol. 20, No. 4(1995): 321-334; MacDonald 1999; and Mona Rosendahl, Inside the Revolution: Everyday Life in Socialist Cuba, Ithaca: Cornell University Press, 1997. 10 American Association for World Health 1997; LuzClaudio, Luz. “The Challenge for Cuba.” Environmental Health Perspectives Vol. 107, No. 5(1999):A246-A251, and Nayeri 1995. 11 In the contexts of both black market activity and personal expression, people regularly use “riesgo” and “arriesgarse” [to risk oneself] as code or slang terms to connote the simultaneous fear and defiance of government authority necessary for their survival. 12 See Laura J. Enriquez, “Cuba’s New Agricultural Revolution: The Transformation of Food Crop Production in Contemporary Cuba,” Development Report No. 14, Food First-Institute for Food and Development Policy (2000). 13 For example, Davis and Low 1989, Finkler 1985. 14 See Mari H. Clark, “Nevra in a Greek Village: Idiom, Metaphor, Symptom, or Disorder?” In Gender, Health, and Illness: The Case of Nerves, ed. Dona L. Davis, and Setha M. Low. New York: Hemisphere Publishing Corporation, 1989; Kaja Finkler, “The Universality of Nerves,” In Gender, Health, and Illness: The Case of Nerves, ed. Dona L. Davis and Setha M. Low, 79-87. New York: Hemisphere Publishing Corporation, 1989; and Rebhun, 1992, also acknowledge that men and women both experience “nerves,” but found it more predominant in women. 15 See Isabel Holgado Fernández, ¡No es fácil! Mujeres Cubanas y la crisis revolucionaria. Capellades (Barcelona): Romanyà/Valls, s.a., 2000;and Rosendahl 1997. As these two authors point out, despite Cuban women’s relative independence and power, there seems to be a general consensus that the Revolution has not fully addressed the problem of machísmo. They argue that women are expected to dutifully bear greater domestic burdens than men, while upholding professional and socio-political responsibilities. I also noticed, however, that many of these same women refuse help from male household members and raise male children to stay out of the kitchen, so to speak.

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___________________________________________________________ 16

See Holgado Fernández 2000, and Michel-Rolph Trouillot, “The Caribbean Region: An Open Frontier in Anthropological Theory,” Annual Review of Anthropology Vol. 21(1992):19-42. 17 Rebhun 1993 18 Here I refer to management of one’s own health by means of any modality considered therapeutic. 19 In the contexts of Spiritism and Afro-Cuban religion montar [to mount] refers to the process in which a spirit “possesses” a medium. 20 See Damian J. Fernández, Cuba and the Politics of Passion. University of Texas Press: Austin, 2000. 21 The noun invento [invention] and the verb inventar are popular Cuban slang terms that refer to stop-gap measures, or improvised substitutes for materials that are lacking due to shortages and poverty. The terms carry mixed undertones: though people are frustrated with their struggles, they are proud of their capacity for innovation and find humour in the absurdity of it all. 22 Scheper-Hughes 1992, 1994; see also Green 1994, Rebhun 1993. 23 For example, Davis and Low 1989; Byron J. Good,“Studying Mental Illness in Context: Local, Global, or Universal?” Ethos Vol. 25, No. 2, Ethnography and Sociocultural Processes: A Symposium, (1997): 230-248; Green 1994, Peter J. Guarnaccia, “Ataque de Nervios in Puerto Rico: Culture-Bound Syndrome or Popular Illness?” Medical Anthropology Vol. 15, No. 21 (1993): 57-170; Arthur Kleinman, Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press, 1988; Rebhun 1993; Scheper-Hughes 1992, 1994; Scheper-Hughes and Lock 1987; Nancy Sheper-Hughes and Margaret Lock, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology,” Medical Anthropology Quarterly New Series, Vol. 1, No. 1 (1987): 6-41; and Woodrick 1995.

Author Traci Potterf has an M.A. in Anthropology from the department of Anthropology at the University of California, Berkeley, where she is currently a Ph.D. Candidate.

The Role of Negative Self-concept in Depression, Stress, and Anxiety of Married Women Banoudokht Najafianpour Abstract In this paper, the use of exercise and pleasant excursion intervention will be outlined with a sample of married women suffering from depression and low-self concept. Having had extremely strict, aggressive, and in some cases closed-minded parents; these women have faced many difficulties during their childhood and adolescence. They were diagnosed as being quite passive and were determined to be suffering from depression. Additionally, according to Roger self-concept test, they had absolutely low and/or negative opinions of themselves. The treatment sample consisted of ten women, chosen randomly. They were involved in first individual treatment and then group treatment. Group physical activities and pleasant excursions were the main part of their treatment. The husbands were instructed to act as observers of their wives’ behaviour, in order to determine changes. After ten weeks and without taking any medication these women demonstrated improved self-concept and more faith in their own abilities. The results of the post-tests have proved their health. 1.

Introduction

The current study is concerned with the matter of depression and negative self-concept in married women, and possible methods of treatment. I begin with a review of the importance of parental influence on self-image; as the population I have worked with indicate that this lies at the base of their difficulties. Next, I will review findings of researchers regarding the efficacy of physical activity in reducing depression and improving self-concept. Finally, I present and discuss the findings of my own study, which utilizes exercise and pleasant excursions to promote well-being. The subjects were married young women who had despot, cruel fathers and mothers who kept silent. The subjects had experienced a painful life during childhood and adolescence. They had not been allowed to express their feelings and inclinations. They had experienced many deprivations in some way or another. They indicated that they cried when they were alone and considered themselves as incapable, inadequate people, and even when it happened that they were at a happy event they could not feel happy. They were not much successful in education, meaning that their average school grades, especially during adolescence,

78 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ were less than that in elementary school; and some had withdrawn from education. They had been constantly experiencing fear and stress and anxiety. They sated that their classmates’ successes made them feel even more incapability and inferiority. The family had worked as an obstacle to their abilities to emerge and develop. Their mother lacked the ability to develop a suitable affective relation. The absence of mental safety in the family had caused the subjects during adolescence to fail to experience stable relationship with their classmates. They had developed an generalized pessimism, so that they feared marriage and were pessimistic about it, although they had been forced by their fathers to marry. Most of the subjects had kind husbands, although the subjects saw their fathers’ faces in the faces of their husbands. Hence, the kind behaviours of their husbands had not given rise to positive changes in them. Recalling such wicked experiences had severely restricted their ability to perform necessary daily tasks; they were also cold in marital relations. Most often they did not experience a pleasant sleep. Those who had a child or children thought of their children’s future as worrisome. The family atmosphere had turned them into cold beings indifferent to life. On the other hand, as they had silent, un-intimate mothers and the natural need to have a kind mother had been suppressed in them, I felt I can attract them as a female therapist; hence, I began to found an intimate relationship with them. And as they did not have positive memories of going out with their parents and rarely went sightseeing, and they hardly practiced physical exercise, I based the therapy upon pleasure excursions and physical activity. A. Early Determinants of Depression and Well-being Family is a system that functions through interactive patterns1. Family is defined to have “sound” and “unsound” functioning2. It has been shown that the inconsideration of child includes such factors as the parents’ inadequacy, social and affective deprivations, too much or too little stimulation, inappropriate expectation from the child, and failure to understand or predict the child’s needs in a certain stage of growth – which causes the child under such circumstances to feel that is not considered and loved by the family. Structural family theorists argue that certain patterns of family interaction and organization promote healthy psychosocial development in children, whereas other patterns result in stress and symptoms3. The American Psychiatry Association (APA, 1994) mentions the negligence of the child’s education. According to Gelles and Straus4, violence in a family may occur in different forms, and may be in physical, emotional or economic forms. It may also be inflicted upon one’s spouse, parents or children, although it is more often inflicted on wives and children. The type of relationship between the child and the parents plays an important role in the formation

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___________________________________________________________ of his or her personality. A very critical point is the child’s understanding of the parents’ appraisals. If the children feel that such appraisal is a positive one they will form a positive, enjoyable feeling of themselves, and if they feel that it is a negative one they will form a negative feeling of themselves and develop a feeling of insecurity5. According to Medinnus and Curtis, the type of acceptance of the child is to a great extent a reflection of their self-acceptance: mothers demonstrating self-acceptance tend to accept their children too. Rogers introduced the concept of “positive consideration”, which comprises talking, loving, respecting and sympathy6. The perception developed by the child of the parents is important and it is the general environment of the family which influences the child’s perception of the parents and their motives. In aggressive families, there is a strong relation between the familial violence and mistreatment of children. The humiliatory messages of parents, by which the child is ridiculed, rejected or terrified, will lead to low self-esteem, high anxiety, blame, and attempt to avoid severe mental sufferings. According to Alfred Adler, the degree of security the child seeks depends on his or her upbringing7. In Raskinn’s study of 16 people with common anxiety disorders, it was found that the way they were brought up was totally irregular and problematic, and the healers regarded their anxiety as being caused by the family environment. Today, theoretical scientists believe that most anxiety disorders may be due to unsound parent-child relationships. The most important factor which causes all mental diseases, on the basis of mental analysis theory, is anxiety8. Freud referred to the anxiety as “psychic pain”, and posits one cause of it being the lack of close familial relations. Rogers emphasizes positive consideration as a definitely important factor for good, sound relations among people. Epidemiological studies of the American Mental Hygiene Institute showed that anxiety disorders and depression were the most common disorders9,10. Crook holds that the attitudes of a person with depression towards the “self” may have been generated under the influence of the unpleasant relationships such people had with their parents during childhood11. According to A. T. Jersild, the self is a compound of thoughts and affections, which make a person aware of his or her existence; that is, s/he will understand who, and what, s/he is. The “self” is the cosmos inside the person. It is said that parents are one of the most important bases for the formation of a picture of the self and respect for oneself. Children who are rejected tend to reject themselves and develop a feeling of lack of value. “Self-perception” refers to a picture we develop of ourselves, which includes strength and values. Therefore, the father’s cruelty and the mother’s lack of intervention in the familial and children’s affairs had

80 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ caused the children to refrain from formation of intimate relation with their classmates in the school. They even felt having low capacity in doing group activities and considered themselves as inadequate compared with others. Seligman says that a low capacity and little interaction with the environment may often be followed by depression12. Toits believes that severe anxiety, agitation and hopelessness may decrease one’s control over his behaviour and lessen his ability to solve problems13. B. Physical Activity and Well-Being. “Fremont and Craighead studied the healing effect of running, cognition therapy and cognition therapy accompanied by exercise on 9 men with weak to moderate depression. The results of the research showed that running was as much effective in treatment of weak and moderate depression as cognition therapy and cognition therapy accompanied by exercise14”. In a study of 43 women with deep depression, Martinesen used individual psychotherapy and occupational therapy for the control group and individual psychotherapy and sports training for the experimental group. He reached the conclusion that the sports training showed more reduction in depression scores and psychopathology scoring than the control group, who did not experience sports training15,16. Stein and Motta examined the effect of swimming and weight-bearing exercises on depression and self-concept in 89 students. A comparison of the results showed that weight-bearing exercises were more effective in lowering the depression and improving the self-concept scores than swimming17. Researches indicate that physical exercises improve the sleeping cycle of people. In research by Waker et al., girls who became more advanced at physical exercises reported improvements in their sleeping. According to Laryman, physical exercise positively influences mental health and social adjustment and there is a close relation between physical health and mental adjustment. Many researches have shown that anxiety subsided after five to thirty minutes of exercise, offering support for the premise that exercise has short-term positive effects18,19. In addition, it has been reported that aerobic exercises help to lower such mental states as anxiety, distress and depression20. Physical exercises are also beneficial in helping to improve affect, and it may be used to provide a person with positive thoughts and affections. Evidence indicates that physical exercise may reinforce a feeling of capability and self-command21. Studies that indicate the anti-

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___________________________________________________________ depressive effect of physical exercise include those conducted by Folkin and Sime22. In a comprehensive study of four women with depression, physical exercise proved to be a beneficial, practicable treatment for women with the disorder of severe depression23. In another study, Doyen et al. examined the effect of running and weight-bearing exercises in the treatment of 41 women with severe depression. After the treatment period was ended and in the one-month period of post-treatment follow-up, the results of the study showed a meaningful decrease in the depression scores of two exercise groups (i.e. walking and weight-bearing exercise). They came to the conclusion that both speed exercises, such as running, and those pertaining to power, such as working with weights, have antidepression effects24. In another study, McCann and Holmes studied the effect of physical exercise and relaxation on depression. The study showed that the depression scores in the group, which practiced physical exercises (track and field), had a meaningful reduction as compared with those who practiced relaxation and those undergoing no treatment25. In his studies, Sime stated that physical activity enhanced mental health, reduced depression and anxiety, led to improved temperament, happiness and positive attitudes, and enhanced self-concept26. Research shows that people who take part in regular physical practices have a better, more positive attitude toward themselves and their capabilities. In a study conducted by Wilfly, the effect of physical activity on the self-concept of physical fitness in adult women was studied. The research, in which 83 people participated and which lasted for 8 weeks, showed that the subjects who completed the 8-week plan of physical fitness practice (i.e. 49 people) demonstrated significantly higher endurance, power, flexibility and physical self-concept than those who did not complete it27. It is believed that physical exercise improves self-concept. The results of various studies indicated that a combination of running as an aerobic activity and supportive intervention helped those with a low selfconcept to develop more positive attitudes towards themselves. Therefore, both aerobic and non-aerobic activities may help to increase self-concept. Berger et al. found a relationship between doing physical activities and the quality of life of adults: doing regular physical exercises improved the mental hygiene and health, especially in such areas as personality, life satisfaction, happiness, self-efficiency, self-concept and positive mental image of one’s physics, in the sense that they develop a positive attitude toward the entirety of their bodies28. In a study conducted by Raglin, “Mental Health and Physical Activities: Benefits and Harms”, he claims that today, physical exercises and activities are increasingly accepted as a means of preserving and

82 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ improving mental health. Several studies support the view that physical activities are accompanied by improvements in various aspects of mental health, such as enhanced temperament and positive self-concept29. In a research study entitled, “The Effects of Learning Sports Skills on the Selfconcept of the Nigerian Youth”, Olusegum (1990) studied self-concept of individuals learning basketball and hockey. The results of his research showed that the raised level of skills in the said sports led to significantly stronger feelings of merit, increased self-confidence, and positive attitudes toward one’s physical health. Also, it seems that expanded capability in such skills will lead to a more positive self-concept and an improved physical picture of the self. The results of studies carried out by Dishman on the physical activity and mental health indicated that physical exercise would decrease anxiety and depression30. The purpose of the present study, in line with other studies, is to determine the role of physical exercise in interventions geared towards reducing or healing depression. 2.

Method

The subjects were selected on a random basis from 100 young married women with a history of depression who, along with their husbands, had consulted the psychology clinic. Then, 30 of them were divided on a random basis to the control group and experimental group. The groups were originally chosen to be parallel. But for various reasons, five people in the experimental group withdrew from treatment and cooperation with the research and so five people were also randomly eliminated from the control group. In the end, the test and control groups each consisted of 10 people. For the purpose of the research, a quasiexperimental design was used, and considering the independent variable, ten weeks of treatment was regarded as suitable, which comprised two sessions per week with each session lasting one and a half hours. At the beginning of the study, the two groups were given the Beck depression test and the Rogers self-concept test as a pre-test. A comparison of the results of both tests for the two groups indicated that the groups did not differ significantly in their levels of depression or selfconcept. Treatment was based in cognitive behaviour therapy theory and contained a number of interventions31. Before the therapy began, the husbands of the subjects in the experimental group were invited to meet individually with the researchers and were given instructions regarding sympathizing with their wives and indirect supervision on their behaviours. Special sheets were given to them in which they recorded their wives’ day-by-day activities and manner of relating and anxieties. They were asked to hand in the completed sheets

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___________________________________________________________ every week by fax or by sending to the special P.O. box., and a number of hours were dedicated to telephone calls so that everybody could keep in touch with us. The husbands of the experimental group generally presented reports in the ten weeks of the experiment. The subjects in the treatment group were given the additional task of aerobic exercise and regular physical activity in the beginning of the fourth week, while we continued other interventions. In the seventh and eighth weeks, the subjects were taken an outing to a beautiful nature area. Thus, a joyful event was included with the physical exercise, as described in the Tenweek Treatment Procedure. The eighth and ninth weeks were considered as the post-treatment follow-up, and the experimental group was given the Beck test and Rogers self-concept test a second time to determine posttreatment scores. A comparison of the pre-treatment and post-treatment test scores as to the experimental group showed that their difference by use of T-test were meaningful (with α=0.05). No therapy was considered from the beginning for the control group and they were introduced to other therapists. Therefore, they conducted no test after completion of the therapy for the experiment group. Again, after four months the experimental group was given the Beck and Rogers self-concept tests, and no meaningful relationship was found between the averages of the experimental group at the end of the therapy and four months later (p< remain in the social memory 0.05). 3.

Ten-week Treatment Procedure

A. First Week: Individual - 1st Session Statement of the purpose of treatment, introduction to each of the subjects, clinical interview and general appraisal of them, and creation of close relationship and winning their confidence. - 2nd Session Creation of such conditions that the subject may recall negative automatic thoughts relating to depression; giving tasks to the subjects based on negative automatic thoughts and appraising them with a rating scale of zero to 100: the score 100 denoted maximum negative automatic thoughts. B. Second Week: Beginning of Group Therapy - 3rd Session Statement of the matter discussed in the previous session in brief, underlying the negative automatic thoughts; recording the subjects’ attitudes toward their spouse with a rating scale of zero to 100; presenting tasks to be done at home for the purpose of self-help.

84 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ - 4th Session Statement of the subjects’ feelings about the therapy with a rating scale of zero to 100: 0 denoted dissatisfaction and 100 denoted utmost satisfaction; statement of self-help activities of each of them. C. Third Week - 5th Session Repeating the discussions of the previous session; discussing the satisfaction from life on the basis of common sense; presence of negative thoughts in each of the subjects and exploring the reasons of thoughts and challenging them by use of reasoning and analyzing thinking; presenting tasks to be done at home regarding what they used to feel unable to do; and appraising the negative automatic thoughts. - 6th Session Struggling the activities which they used to consider themselves unable or too weak to do (by focusing on the situation) and using distraction techniques, such as playing sounds of birds while the subjects were seeking certain properties in the paintings on the wall. This technique served to hinder the person from recalling the bad memories of the past. D. Fourth Week: Aerobic Exercise - 7th Session Alternately discussing the effect of physical exercise on stress, anxiety and depression and playing the aerobic exercise video; to practice regular physical exercises, while focusing on the logical order of movements as a technique of distraction. - 8th Session Carrying out physical practices two by two and doing the aerobic exercise for a second time; discussing the development of capability by exercising; and writing down the subjects’ attitudes towards their spouses as a home task. E. Fifth Week - 9th Session Statement of changes following from physical exercise; playing a movie showing physical exercises and women’s successes and discussing them; carrying out regular physical practices; carrying out aerobic exercise; and summing up what they could recall from the previous sessions; and appraising their feeling toward the treatment with a rating scale of zero to 100. - 10th Session Discussing the capabilities of themselves which they did not use to believe in, for example change in their attitude toward and getting

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___________________________________________________________ interested in sports, making telephone calls to new friends they had found during the process of therapy, attaching importance to the decoration and furniture of their houses, and doing the home tasks; and assigning two short periods of time in a day to physical exercise. F. Sixth Week - 11th Session Discussing the home tasks and changes caused by physical exercise; entering the negative automatic thoughts in the appraisal sheet with a rating scale of zero to 100 and giving the subjects the chance to discuss them; doing physical exercises joyfully. - 12th Session Carrying out the aerobic practices for longer than half an hour; discussing their behavioural changes at home and its effects on the dayby-day activities and relation with the spouse with a rating scale of zero to 100, and proposing to them to carry out the practices outside the clinic (in the beautiful nature). G. Seventh Week - 13th Session Taking the subjects to a pleasant excursion in nature and having them to do physical exercises, especially aerobic ones, and using the distraction technique, including distracting their focuses to the flowers and stating the similarities between the flowers; walking not so fast and not so slow; presenting home tasks; summing up the matters discussed in the session. - 14th Session Discussing the home tasks; appraising the pleasant feeling toward the treatment with a rating scale of zero to 100, in which 100 denotes maximum satisfaction; concentrating on the aerobic video and doing aerobic exercise for five minutes without the video; summing up the session. H. Eighth Week - 15th Session The subjects were asked to walk and express a sentence after counting three numbers: “one, two, three, I am the rain – one, two, three, I am raining – one, two, three, I make all the herbs grow – one, two, three, I give happiness to everybody”. Then these sentences were uttered more loudly. They expressed their pleasant feeling about the treatment. - 16th Session The subjects concentrated on the music which was played and then they began to practice aerobic exercise. At the suggestion of the subjects, the contents of the fifteenth session were repeated more joyfully

86 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ and jovially. The subjects were asked to make a sum-up of the treatment sessions. Diagram 1, shows the general appraisal of negative automatic thoughts for the first week until the end of the seventh week (14th session). Diagram 2, shows the general appraisal of the subjects’ attitudes toward their husbands (3rd session, 8th session, 12th session, and 15th session). Diagram 3, shows the subjects’ satisfaction toward the treatment (4th session, 9th session, and 14th session). 80 0 Min. nega tive automatic thoughts 100 Max. nega tive automatic thoughts

70 60 50 40 30 20 10 0 0

2

4

6

8

10

12

14

16

Ses s ion

Diagram 1. General appraisal of negative automatic thoughts 90 80 70 60 50 40 30 20 0 Min. positive attitude tow ard one’s husband 100 Max. positive attitude tow ard one’s husband

10 0 0

2

4

6

8

10

12

14

Session

Diagram 2. General appraisal of the subjects’ attitudes toward their husbands

16

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___________________________________________________________ 90 80 70 60 50 40 30 20 0 Lack of satisfaction 100 Max. satisfaction

10 0 0

2

4

6

8

10

12

14

16

Session

Diagram 3. The subjects’ satisfaction with the therapy

4.

Statistical Analysis

The t-test for independent groups showed a meaningful difference between the results of pre-T and post-T at α=0.05 (see Table 1). Depression scores were considered as following: normal<10, mild 10-19, roughly severe 20-25 and severe >25. Self-concept scores were included; negative self-concept and neurotic tendency=7.01-10.00, neurotic self-concept >10.01. Table 1. The t-test for independent groups showed a meaningful difference between the results of pre-T and post-T at α=0.05. (Mean of experimental group ( x1 ), mean of control group ( x2 ). Critical T-score=2.101; d.f. = 18, P < 0.05)

88 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ Pre-T

Post- T

N

x1

x2

t

x1

x2

T

Self-concept

10

9

9.52

1.06

6.3

9.52

7.3

Depression

10

21.6

22.7

1.99

10.5

22.7

10.16

5.

Discussion

The subjects were married young women who attended the consultation clinic, while their husbands were accompanying them. At the beginning of the therapy, after general information was obtained about the subjects, their husbands were instructed to indirectly write down the subjects’ behaviours. The subjects had undergone medicinal therapy, but they had given up treatment before it had been completed. They had also consulted psychological clinics; however, they had not managed to continue the treatment. Therefore, the first two sessions of treatment were held individually. The aim was to attract the individual subjects and build their confidence. Using other interventions in addition to physical exercise caused significant changes in their behaviour. The “out-of-home method”32, along with the independent variable of physical exercise, led to a high level of mental-physical fitness in the subjects. The diagrams show that the variable of physical exercise, especially aerobic done outdoors, is more effective in lessening or treating depression. Following the cognitive model, Beck et al. and Ossip-Klein et al. underline the improvement of self-concept as the principal element of antidepressant effect of physical exercise, especially when the exercise is accompanied by joy and pleasure33, 34. It must be mentioned that four months from the end of the treatment, the results of Beck depression test and Rogers self-concept test did not show meaningful difference with those conducted immediately after the treatment was ended. Thus, the beneficial aspects of the therapy appear to have lasted even after the therapy was completed. I have carried out five other similar studies and strongly believe in the effectiveness of physical exercises accompanied by pleasure and recreation in treating depression and stress and improving self-concept.

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___________________________________________________________ Comments In light of the question about the possibilities of having aerobics classes in Iran, it must be mentioned that performing such activities and exercises in separated sessions/classes for women and men, is quite possible and permitted, as they were arranged for the subjects who attended our consultation office. As an example and complementary explanation to the distraction technique, which was also asked in the conference, it can be said that, referring to this technique, subjects were asked to for example, characterize all the surroundings and available stuffs in the office, according to their shape, size, colour, similarities and differences. In addition, the subjects were asked to explain why and how those items are used. Another application of this technique was where the subjects were asked to write the girls' names, which start with special letter, and/or the boys' names, which end with special letter. This technique, applied in the th 6 session, was extremely helpful for increasing the concentration abilities of the subjects. The remarkable results of this technique showed up in session 13, when it was practiced together with physical activities. Proposal I hope that psychologists use different variables accompanied by pleasure and happiness for treatment, because every person’s need for happiness and joyfulness is like the fish’s need for water.

Notes 1

S. Minuchin & H.C. Fishman. Family Therapy Techniques (Cambridge, MA: Harvard University Press, 1981). 2 F. Walsh, "Conceptualization of Normal Family Processes" in Normal Family Processes, 2nd edition, ed. F. Walsh, (New York, NY: Guilford Press, 1993). 3 D.A. Madden-Derdich, A.U. Estrada, K.A. Updegraff, & S.A. Leonard, “The Boundary Violations Scale: An empirical measure of intergenerational boundary violations in families,” Journal of Marital and Family Therapy, 28 (2002): 241-54. 4 R.J. Gelles & M.A. Straus. Intimate violence (New York, NY: Simon & Schuster, 1989). 5 L.A. Pervin, Personality: Theory and research, John Wiley and Sons Ltd, 1989. 6 C.R. Rogers, Client Centered Therapy (Boston: Houghton Mifflin Co., 1982).

90 The Role of Negative self-concept in Depression, Stress & Anxiety ___________________________________________________________ 7

A. Adler, Understanding Human Nature (Center City, Minnesota: Hazelden, 1989). 8 J.C. Coleman, Abnormal psychology and modern life, Fourth Edition, (Glenview, Illinois, London: Scott, Foresman and company, 1972). 9 R. Michaels & P.M. Marzuk, “Medical Progress: Progress in PsychiatryFirst of Two Parts,” The New England Journal of Medicine 329 (1993):552-560. 10 R. Michaels R & P.M. Marzuk, “Medical Progress: Progress in Psychiatry- Second of Two Parts,” The New England Journal of Medicine, 329(1993): 628-638. 11 J.M. Zarb, Cognitive-behavioral assessment and therapy with adolescents (New York: Brunner/Mazel, 1992). 12 M. Seligman, Helplessness: On Depression, Development, and Death (New York: W. H. Freeman, 1975). 13 P.A. Toits, “Social Support as Coping Assistance,” Journal of consulting and clinical psychology 54 (1986): 416-423. 14 J. Fremont & L.W. Craighead, Aerobic exercise and cognitive therapy for mild-moderate depression. (Presented at the Association for Advancement of Therapy: Philadelphia, PA, 1984). 15 E.W. Martinsen, A. Medhus & L. Sandvik, “Effects of aerobic exercise on depression: A controlled study,” British Medical Journal, 291 (1985):109. 16 E.W. Martinsen, L. Sandvik, O. Kolbjornsrud, “Aerobic exercise in the treatment of nonpsychotic mental disorders,” Norwegian Journal of Psychiatry, 43 (1989): 411-415. 17 P.N. Stein & R.W. Motta, “Effects of aerobic and nonaerobic exercise on depression and self-concept,” Perceptual and Motor Skills, 74(1992): 79-89. 18 J. Moses, “Light exercise may yield more mental benefit.” Family Practice News, 19 (1989): 51. 19 A. Morse, R. Walker & D. Monroe, “The effect of exercise on a psychological measure of the stress response,” Wellness Perspectives, 11, 1(1994): 39-46. 20 A.D. Simons, L.H. Epstein, C.R. McGowan, D.J. Kupfer, & R.J. Robertson, “Exercise as a treatment for depression: an update,” Clinical Psychology Review, 5 (1985): 553-558. 21 N.R. Carlson & W. Buskist, Psychology: The Science of Behavior, Fifth edition, (Allyn and Bacon, 1997). 22 C.H. Folkins & W.E. Sime, “Physical Fitness Training and Mental Health,” Amer. Psych. 36 (1981): 373-389. 23 E.J. Doyne, D.L. Chambless, L.E. Beutler, “Aerobic exercise as a treatment for depression in women,” Behavior Therapy, 14 (1983): 434-440.

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___________________________________________________________ 24

E.J. Doyne, E.D. Bowman, D.J. Ossip-Klein, K.M. Osborn, I. McDougall-Wilson, & R.A. Neimeyer, A comparison of aerobic and nonaerobic exercise in the treatment of depression (Washington DC: Association for the Advancement of behaviour therapy, 1983). 25 I.L. McCann & D.S. Holmes, “Influence of aerobic exercise on depression,” Journal of Personality and Social Psychology 46 (1984) 1142-1147. 26 W.E. Sime, “Exercise in the prevention and treatment of depression: 135-152.” In Exercise and mental health, ed. W.P. Morgan and S.E. Goldston. Washington, DC: Hemisphere, 1987. 27 D. Wilfley & J. Kunce, “Differential physical and psychological effects of exercise,” Journal of Counseling Psychology 33 (1986): 337-342. 28 B. Berger & D. Owen, Stress Reduction and Mood Enhancement in Four Exercise Modes: Swimming, Body Conditioning, Hatha Yoga, and Fencing, (Brooklyn, NY: Research Quarterly For Exercise and Sport, 1988). 29 J.S. Raglin, Exercise and Mental Health. Beneficial and Detrimental Effects. (Bloomington, Indiana: Sports Med., 1990). 30 R.K. Dishman, Biological Psychology, Exercise, and Stress. (Athens Georgia: American Academy of Kinesiology and Physical Education, 1994). 31 K. Hawton, P.M. Salkovskis, J. Kirk, & D.M. Clark (eds.), Cognitive Behavior Therapy for Psychiatric Problems – A Practical Guide. (Oxford: Oxford University Press, 1989). 32 K.I. Pakenham & M.R. Dadds, “Family care and schizophrenia: the effects of a supportive educational program on relatives' personal and social adjustment,” Australian and New Zealand Journal of Psychiatry 21 (1987): 580-90. 33 A.T. Beck, A.J. Rush, B.F. Shaw & G. Emery, Cognitive therapy of depression, (New York: Guilford Press, 1979). 34 D. J. Ossip-Klein, E.J. Doyne, E.D. Bowman, K.M. Osborn, I.B. McDougall-Wilson, & R.A. Neimeyer, “Effects of running or weight lifting on self-concept in clinically depressed women,” Journal of Consulting and Clinical Psychology 57 (1989): 158-161.

Acknowledgment The author acknowledges Islamic Azad University, Karadj Branch, for financially supporting this research.

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Hong Kong’s Female Sex Workers: Stress and Anxietyrelated Consequences of the Intersection of Poverty, Gender, Dangerous Work Eleanor A. Holroyd, William C.W. Wong, Davina C. Ling, Ann Gray Abstract In Hong Kong, it was estimated that there were at least 200,000 female sex workers (FSWs) in 2002 and the total female population involved as workers, supporting staff and partners of the male clients exceeded half a million in a city of 6.8 million people. A self administered questionnaire comprised of 6 different domains, focusing on health behavior, environment and lifestyles was administered to a total sample of 89 FSWs, in addition, one focus group was conducted. The mean age of the FSWs interviewed was 36.1 years with the majority having received no more than junior high school education. Sixty-eight women (76.4%) had been in Hong Kong for less than one year and 35 (39.3%) for less than three months. A total of 14 (15.7%) of the women reported being robbed and verbally abused by client respectively. Furthermore, 7 (7.9%) of the women had been beaten by clients. A number of women (12.4%) had been insulted by passers-by. Many women felt physically unsafe and 18 (20.2%) reported only receiving irregular payment. Recommendations are to promote FSW peer education and empowerment and to address the complex stigmatization and victimization that operates for FSW. It is paramount to address the complexity of mental health risks and costs in relation to commercial sex which are further compounded by underlying factors of poverty, illegal statuses, marginalization, ethnicity and uncertainty so informing anxiety and depression outcomes. 1.

Introduction and Background

Sex work is characterized by a “complex organizational structure.”1 Migration for sex work is increasingly internationally, yet hard to measure. This is particularly so given the lack of documentation of what in most countries regarded as an outlawed and underground activity, and the multitude of activities world-wide that constitute sex work In Hong Kong, it was estimated that there were at least 200,000 female sex workers (FSWs) in 2002.2 and the total female population involved as workers, supporting staff and partners of the male clients exceeded half a million in a city of 6.8 million people. This is further

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___________________________________________________________ fuelled by closer integration and high volume of cross-border travel between China and Hong Kong in the recent years.2 .In recent years there has been a considerable rise in the number of mainland Chinese female street sex workers. In 2001 there were 3,057 mainland Chinese arrested on suspicion of engaging in prostitution and in 2002, there were 8,455 similarly arrested.2 Studies have concentrated on sexually transmitted infections (STIs): rates and HIV/ STDs prevention objectifying sex workers as reservoirs if not ‘vectors’ for the transmission of STDs with few personal negotiating abilities The World Health Organization advised that successful interventions to prevent HIV infection associated with prostitution “…have been most effective where prostitutes are empowered to determine their working conditions.”3 Arguments for and against the work place support of sex workers are abundant in the literature. Instead of regarding women as being forced or lured into prostitution, pro-sex work campaigners argue that sex work should be treated as an occupation deserving of occupational safety.3 The international literature notes that prostitutes do not play a decisive role in the spread of the disease instead it is recommended that all research and interventions should directly address the socioeconomic context of women’s lives and the multiplicity of health concerns in order to improve women’s health. In Hong Kong, prostitution and the social processes behind prostitution have largely been ignored whereas the visible face to the public has been that of media reports of regular police raids because of the increasing number of mainland women who enter Hong Kong illegally to engage in this industry.4 The context of economic necessity and illegality of sex work renders (migrating) sex workers extremely vulnerable to public stigma, occupational injury and harassment. This in turn violates their human rights in numbers of ways which remain scarcely and very poorly documented in the international research literature. Women in prostitution are denied their civil rights and such denies women's humanity. In prostitution, women are exposed to frequent rapes, stigma and humiliation .Prostitutes are frequently subject to cruel and brutal treatment without human limits; it is the opportunity to do this that is exchanged when women are bought and sold for sex.5 Furthermore security and a safe environment of the person is fundamental to society, whereas prostitution transgresses women's personal security. In prostitution women have no channel for protection because of the insecure nature of their work.6

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___________________________________________________________ 2.

Method

Between October 2003 and February 2004, the Chinese University of Hong Kong and a local charity, Action for Reach Out (AFRO) conducted a survey on the female street sex workers in four low socio-economic districts of Hong Kong; the Shamshuipo, Yaumatei, Jordon and Sanpokong districts. AFRO was started in 1993 and was the first non-governmental organization working for the rights and better health of these women in Hong Kong. It has an extensive outreach network and has got to know many street workers over the years. A research assistant invited a convenience sample of the street workers drawn from the outreach to participate a 30-minute face-to-face interview at the AFRO drop-in centre. Convenience sampling was selected due to the fluid, often illegal and frequently hard to reach nature of female street sex workers in Hong Kong. A small gift worth HK$30 (US$1=HK$7.8), of face cream and a key ring was given to the women as a token of appreciation of their time. The cost of this gift was roughly equivalent to ten percent of the cost of the sexual services that the women performed and would have had minimal impact towards their living expenses. In Hong Kong, a gift and exchange based society, it is common practice to provide a gift as visible evidence of appreciation to research volunteers. The questionnaire consisted of two parts: The first section was the abbreviated version of the World Health Organization Quality of Life (WHOQOL-BREF) 6 Measure7 and the second part comprised of 6 different domains, of which the environmental domain (including personal safety, home environment, health and social care, opportunities for recreation) is reported. Owing to the need to elicit more contextual data that arose as a result of the survey, it was considered necessary to hold a focus group. The questions asked in the focus group were designed to elicit an understanding of the thinking and context behind the central issues from the questionnaire. 3.

Results

A. Demographics A total of 89 street workers were recruited for this study with a mean age of 36.1 years and with the majority having received no more than junior high school education. Six women (6.7%) were Hong Kong residents while the rest had come from Mainland China with the exception of two women who had come from Thailand. Therefore, it was not unexpected that 68 women (76.4%) had been in Hong Kong for less than one year and 35 (39.3%) for less than three months. About half of the

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Hong Kong’s Female Sex Workers

___________________________________________________________ women surveyed were married - (49.4%) and had a job before (52.8%), which included manufacturing work, (40.3%), self-employment (29.8%) and farming (12.8%) as well as a cluster of other semi skilled occupations such as manicurist. However, low income (46.7%), family factors and debts (19.1%) and factory closure (14.9%) were the most common reasons for entering the sex trade. The characteristics of the women surveyed are shown in Table 1. Table 1. Characteristics of street FSWs Demographic characteristics Age Mean Range Place of Origin (Percentage) Hong Kong Thailand Hubei (China) Guangdong (China) Hunan (China) Others ( China) Time living in Hong Kong < 3 months 3 months-1year 2-10 years 11-20 years 21- 30 years >30 years Marital Status Single Married and live with husband Married but do not live with husband Co-habited Divorced Widow Number of dependents 0 1 2 3 4 Education level No formal education or kindergarten Primary school Low secondary school

Years 36.07 23-58 (%) 12 2 33.7 25.8 14.6 14.7 39.3 37.1 3.4 4.4 5.6 10.2 10.1 49.4 14.6 1.1 23.6 1.1 18.0 47.2 30.3 3.4 1.1 5.6 29.2 49.4

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___________________________________________________________ High secondary school Matriculation Income US$2564 Percentage of money spent on self per month <30% 30%-49% 50%-79% 80%-100% Money spent on food per day US$15.3

14.6 1.1 N 53 31 4 1

(%)

28 30 15 16

31.5 33.7 16.9 17.9

45 31 12 1

50.6 34.8 13.5 1.1

59.6 34.8 4.5 1.1

In respect to income, a total of 54.8% of the FSWs surveyed made a living “for the whole family” of less than $5,000 (HK) per month, while 41.1% made between $5,000 and $10,000 (HK) per month, indicating that for the majority, their income was below $10,000. In Hong Kong, the current poverty line lies at $HK3,750 per person. The focus group indicated that many of these women sent their income back to China where it went considerably further to support their families given the much lower cost of living, clearly showing that in Hong Kong, sex work by mainland Chinese women is a strategy of economic migration. Of note is that 71.2% of sex workers did not receive any tips from their clients. A total of 65.2% of the sex workers spent less than 50% of their income on themselves and 50.6% spent less than US$5.1 on food per day. Children’s education took priority and a large amount of the expenses. As Ms Yuen said, “Is it ok to use real names or do we have to specify these are fake names?” And Ms. Chang went on to say, “I have 2 tutors, one for each son and that costs her 300 Yuan per month per tutor.” Almost half of the women worked 7 days a week (47.2%) and 20.2% worked 5 days a week. This is in contrast to a Beijing FSW study in which women worked on average 3-4 days per week.8 Most of the women worked during the day (73.1%), and many (13.5%) worked more than 10 hours a day. The majority of women were flexible in their working hours (38.5%) with the next most frequent group being those who worked early (7-9am) mornings (28.1%) and then late (10-12am) mornings (25.9%). This would mean a lot of the time these women’s working

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___________________________________________________________ environment was on the street with associated public and police harassment. Women were also concerned about poor housing (3.2 vs. 3.5 in non FSW). This concern may well reflect an unsafe working environment in that many of these women worked from home. Clearly the home did not provide a safe or satisfactory environment, which may well contribute to findings of a higher psychological anxiety in comparison to the QOL findings (2.8 vs. 3.3 in non FSW). A total of 84.3% of the women surveyed did not have special reasons for deciding their working hours, reporting that this was a personal decision (71.9%) or arbitrary (12.4%); a few women would work according to clients’ preference (6.7%). A total of 80 of FSWs said that they would stop working when they were sick (89.9%); and most of them would not work when they had their menstrual period (87%). A total of 14 (15.7%) of the women reported being robbed and verbally abused by client respectively. Furthermore, 7 (7.9%) of the women had been beaten by clients, and 2 (2.2%) had been forced to offer services. Forty-seven women (52.8%) had been checked for their ID by police. In addition, 11 (12.4%) of the women had been insulted by passers-by. In addition, two women reported being raped by a client. Many women felt physically unsafe and 18 (20.2%) reported only receiving irregular payment. In the focus group, women gave considerable evidence of clients refusing to pay, for example, one woman reported a man being unable to get an erection and so she had to spend an hour with him. He then refused to pay and threatened to call the police. She chased after him and shouted that he should pay for her service. Some women alluded to finding ways to protect themselves for example, Mrs Yuen said; Being more careful and choose clients carefully – keep handbag away when get to the flat). Do not take off clothes until client starts to do so. If a client does not want to have a shower first, ask him to take off clothes and if he doesn’t want to take off the clothes, ask the client to pay first and if he also refuses, turn him away. (If a man is willing to shower, he will be alright as he is wet and has no clothes, he can’t run away.” It is difficult for FSWs to offer safety, support or protection to one another as their work is both competitive and highly personal. As Ms Yu indicated, “I get no help from the sisters (a solidarity name for other women in the same profession). It is a job that one has to go alone with the client and so the sex worker has to be ‘smart’”.

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___________________________________________________________ The use of the term sisters is a Cantonese colloquial term to refer to women within the same occupation and often from the same province of China. Yet because of the competition for clients that exists among street workers, help is seldom and what might be offered would be of a limited nature. Some women alluded to the fact that because sex work was a “profession,” and thus took more effort to protect themselves by using condoms so they could feel safe sexually, Thus occupational sexual safety was less of an danger than was personal security, for the women sexual services took on an aspect of professionalism which they themselves had potentially greater control over their legal safety. For example, the women interviewed insisted that they made their clients wear condoms. Some women were, however, more concerned about their families’ safety than their own. For example, Ms Yuen stated, “I will phone home every few days and go home every month or every few months to make sure that the family is okay.” To avoid being arrested, most women stopped working temporarily (83.1%) whereas a number of women had no particular strategy (13.5%) Few women knew their rights after being arrested (84.3.0%). Those who had knowledge of their rights reported keeping silent (50%) and bailing themselves out of jail (28.6%) as necessary. In respect to the focus group data Ms Chuen reported an incidence of abuse by the police: “Two policemen said that they were arresting us for ‘blocking the street’. We replied we were travelling from China and had the right to stand there. The policemen then began to verbally insult us by calling us names (prostitutes). When we threatened to complain, the police did not stop, but punched us twice in front of everyone on the street.” Another woman went on to say, “as soon as we are caught, we will be repatriated to the Mainland on the next day and there wouldn’t be a chance to complain, especially when we come in with a fraudulent visa.” 4.

Discussion

The results showed that most of these FSW’s had crossed the border to work in Hong Kong for economic reasons. They tended to be less educated and older than the general population of FSW in Hong Kong9, furthermore, they tended to work long hours. Thus the unpredictability of the street in terms of harassment by the police and vulnerability to passers means the occupation demands full

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___________________________________________________________ attention. Thus sex work itself poses a high degree of occupational danger from which very little protection is offered and women must remain highly vigilant. What are at stake here are issues of power and powerlessness in which visible and overt forms of domination is exerted on sex workers lives through the current legal system. While prostitution is not illegal in Hong Kong, virtually every activity connected with it is. Due to the illegal working status of these Mainland FSW’s no protection is available from the police nor can crimes occurring at or outside work be reported without being risked of criminal charges or deportation themselves. When combined with economic hardship and vulnerability these all contribute to a state of helplessness and entrapment with the associated detrimental effects on their health. Sex work therefore carries a double stigmatization accorded Rubin’s10 sexual hierarchy, in which prostitution falls at the lowest rung being regarded as ‘bad’, ‘abnormal’ or ‘unnatural’ as it is ‘promiscuous, non-procreative, causal and commercial’. Stigmatization’ occurs both at the personal and societal levels, arising from occupational risk of violence as well as being publicly stigmatized carriers of diseases. This may contribute to their poor psychological and physical health. In terms of human rights, despite the pro-feminist debate on FSWs being active in decision-making, the link between poverty and prostitution needs to be addressed in the case of mainland female sex workers. In particular, the income disparities between Hong Kong and Mainland China adds poignancy to the economic hardship of these women and limits the free choice argument Another factor may be that sex work for some of these women provides the opportunity to live an autonomous life, in which they are no longer dependent on an abusive, unreliable, or unfaithful partner. These social and structural processes may contribute to further diminishing their health, quality of life and utilization of services. An added concern is the possibility of misunderstanding and stigmatization by the public, legal services and health professionals. In respect to occupational health and safety of sex workers, Hong Kong laws offer little protection. Besides inhibiting the promotion of safer sex information and associated products (a significant workplace hazard), commonplace practices include arbitrary and unfair work rules such as unfair dismissals, bonding, fining and withholding payment to sex workers. Regardless, many sex workers in massage parlors and escort agencies are not allowed to decline clients or determine their own work hours. Conviction for a prostitution-related offence can erode self-esteem and affect sex workers for the rest of their lives, impairing their ability to gain alternative employment, to travel, and to obtain financial or insurance services.

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___________________________________________________________ Female sex workers represents an at risk population both due to unfamiliarity with the host country health services, their frequently illegal status, powerlessness, stigmatization and marginalisation in respect to occupation, social class, education and language. Stigma puts an enormous burden onto the social lives of sex workers (and one their relationships with private partners if they have them). The management of “double lives” is stressful and hazardous for social support structures, both within and outside the working context.11 5.

Conclusion and Recommendations

This paper has highlighted the extensive psychological and safety concerns that insecurity and heightened vulnerability of sex as work poses. Hong Kong’s existing laws reflect and perpetuate historical inequalities and double standards in relation to women and man, workers and clients, owners and staff being designed to criminalize the sex worker while offering legal protection to the client. Sex workers are denied the protections other workers have a right to expect, (ergo, the right to negotiate the terms and conditions of their employment, the right to a healthy and safe working environment and freedom from sexual harassment). This inequality before the law makes sex workers vulnerable to intimidation and exploitation by clients and employers, including the owners of sex industry premises. It is timely, therefore, to re-open this debate on legal protection and health protection for sex workers to include all involved (FSW, police, legal services, health professionals, mamsans, nurses, NGO staff and volunteers) as well as public awareness come to a human rights based approach to this issue It will be more realistic to balance the basic rights of these vulnerable women such as access to health care and safety without advocating for such activities.12 Closer working relationships should be encouraged between sex workers, sex industry owner/operators, health agencies and local authorities, with the aim of developing a healthy and safe environment which affirms the rights of sex workers and balances the rights of the public.

Notes 1

2

N.J. Davis, (Ed.), Prostitution. An international handbook on trends, problems, and policies, Westport/London: Greenwood Press, 1993. M.K.T. Chan; K.M. Ho; & K.K. Lo, “A behaviour sentinel surveillance for female sex workers in the Social Hygiene Service in Hong Kong (1999-2000),” Int J STD AIDS 13 (2002): 815-20.

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Hong Kong’s Female Sex Workers

___________________________________________________________ 3

C.A. MacKinnon, “Prostitution and Civil Rights,” Michigan Journal of Gender & Law 1 (1993): 13-31. 4 J.T. Lau; A.S. Tang, & H.Y. Tsui, “The relationship between condom use, sexually transmitted diseases, and location of commercial sex transaction among male Hong Kong clients,” AIDS 17 (2003):105-12. 5 Global Programme on AIDS and Programme on STD. Consensus Statement from the Consultation on HIV Epidemiology and Prostitution. (Geneva: World Health Organisation, 1989). 6 C. Pateman, The Sexual Contract (Stanford, California: Standford University Press, 1998). 7 Hong Kong Hospital Authority. Hong Kong Chinese Version of World Health Organisation Quality of Life Measure Abbreviated version (WHOQOL-BREF (HK)) 1997. 8 S. J. Roger, Y, Liu, T.X. Yan, F. Kee, & J. Kaufman, “Reaching and Identifying the STD/ HIV Risk of Sex Workers in Beijing,” AIDS Education and Prevention, 14 (3) (2002): 217-27. 9 K.H. Wong; S.S. Lee; Y.C. Lo; & K.K. Lo, “Condom use among female commercial sex workers and male clients in Hong Kong,” Int J STD AIDS 5 (1994):287-289. 10 I. Vanwesenbeeck, “Another Decade of Social Scientific Work on Sex Work: a review of research 1990-2000,” Annual Review of Sex Research Vol. XII (2001): 242-289. 11 Human Rights Law Review. Proceedings of Trafficking in Persons Conference, Trafficking of Women into Hong Kong for the Purpose of Prostitution. 2003. 12 Travis Kong, “What It Feels Like for a Whore: The Body Politics of Women Performing Erotic Labour in Hong Kong,” Gender, Work and Organisation, v 12, (2004): 201-223.

Authors *Dr. Eleanor A Holroyd RN,RM PhD( Med Anthro). Contact. Associate Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong. Dr. William CW Wong MB ChB (Edin) MRCGP (UK), Assistant Professor, Department of Community and Family Medicine, Chinese University of Hong Kong. Dr. Davina C Ling PhD, Department of Economics, California State University, Fullerton California, USA. Sister Ann Gray, Former Coordinator, Action for Reach Out ( AFRO), Hong Kong.

We Aim To Pee: Unmasking the Secret Phobia and Reducing Performance Anxiety Alex P.W. Gardner Abstract There is a little known condition known as Avoidant Paruresis (AP); also known as Shy Pee or Bashful Bladder. The condition affects people’s ability to urinate in public toilets, or at home when there are others present and in the growing demand for the production of mandatory urine samples. This affects some 7% of the population of Westernised countries. The problem is so severe for some that they are unable to attend work or form lasting social relationships. They will not go out with friends fearing that they will be exposed to humiliation or ridicule. The anxiety levels that many people experience further fuels the phobic state and causes lasting feelings of helplessness and depression. The secrecy is such that people with AP will not disclose this to their partners, even partners of very long standing, and will carry the burden of guilt and shame alone. In this sense AP is a living disability. This paper explores some of the possible psychological factors contributing to this condition. It will suggest factors in the personal subjective reality of the individual using the real world model. This model suggests that the perception of the person can be related to three major elements; identification, orientation, and expectation. In essence these are factors relating to: a) How the concepts and constructs learned and stored from the past are accessed, b) The dynamics of approach and avoidance behaviours in the present and c) The role of expectations about the future From this concept of personal reality the phobic state of paruresis will be examined and implications for treatment and therapy in paruresis explored. The concept of a dynamic Quality of Life for the paruretic will be introduced and elements of this related to the context of interpersonal relationships and the living environment. 1.

Introduction

In psychology there is a condition known as Learned Helplessness. This happens when people have had a series of disappointments and seeming failures that have led them to believe they are useless and simply can’t do anything. This is especially true when having lived with a chronic illness for many years and having tried all the

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___________________________________________________________ conventional therapies with no avail, they feel a sense of hopelessness and are desperate for a treatment that works and which relieves their symptoms. When the health problems come under the heading of ‘embarrassing illnesses’ then the problems are made even worse. People may not seek help from the GP or nurse. They will not talk about the problems with partners or share with others the misery they live with. Convinced that he or she is the only person in the world who cannot urinate in public facilities, someone who has paruresis will not tell anyone about it. In desperation sufferers will turn to therapies that promise relief and offer hope; but mostly deliver nothing. The result of these failures to find a cure leads to more disappointment and regret and consolidates the emotional despair of being helpless. People learn to feel useless. There are often marked signs of anxiety in specific situations. If the precipitating situation involves some kind of public performance then this makes the problems worse. When the problem has psychological overtones and visible observable behaviours as seen in some forms of social phobias then feelings of shame and helplessness are particularly high. This is especially true of what is known as Shy Pee or the Secret Phobia. To try to understand this problem we must first examine and try to understand some of the psychological processes that may be at work in this condition. And from this understanding, unmask the pathologies of the condition and hence develop treatment programmes that can reduce performance anxiety. 2.

Hidden Secrets

Potentially millions of people in the UK hide what is to them a dark secret. This is something they will not disclose to their family, their friends, or their partners. They may have hidden this secret for more than 40 years. The secrecy disrupts their social life, their work, and the family relationships. When things get difficult or uncomfortable at work some people may even resort to changing jobs rather than disclosing their problems to others. They can feel discriminated against and made to feel inadequate. If a person with this problem is asked to go out for a drink, or to go on holiday they often refuse rather than let people know the real reason why they will not socialise. In families, holiday times are a nightmare, frequently with the sufferer refusing to go and not giving reason for refusing. Men will not take their wives or girlfriends out for a meal or to a theatre show. Dads will not go to the football match with their sons. They will not go out to office parties.

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What is this Problem?

Imagine walking into a room somewhere and feeling anxious. Your whole body becomes tense. Your mind goes into overdrive trying to tell the body to relax, but the tension stays the same. Your breathing becoming rapid and you may break out into a sweat. You think that everyone is watching you and noting your every movement. You imagine what they are thinking. You feel that they are laughing at you. Now imagine the room you are in is a public toilet and that you urgently want to urinate, desperately need to urinate, but you cannot go. Despite a full and painful bladder you want to go but just wait and nothing happens. As you wait the tension become worse. You are in pain and frantic to urinate but nothing happens. Due to psychological factors your system shuts down, blocking urination. Despite your distress you leave the toilet in pain. You suffer physically and emotionally. The failure has reinforced your belief that this is something you can’t cope with. You know that every time you try you will feel a failure. You avoid public toilets and devise strategies to urinate at home and resist taking in a normal amount of fluid. You experience a deep, personal, and lasting sense of shame. 4.

Paruresis

Paruresis had previously been classified as a social phobia but current thinking about paruresis is that for diagnostic purposes it is classified as a Social Anxiety Disorder (SAD) in the Diagnostic and Statistical Manual of Mental Disorders-IV 300.231. However, this classification does not mean that a person with paruresis is “mentally ill.” As yet paruresis is so little understood that this classification is for convenience. For many people however, paruresis is still looked on a social phobia. It is also called the Secret Phobia. There are two primary types of SAD: Specific and Generalised. A. Specific SAD Specific social phobias involve a focused area of fear, discomfort, and avoidance. Though relatively comfortable in most social situations, individuals with a specific social phobia dread one or a limited number of particular situations. Common examples of these situations include: • Public Speaking • Entertaining an Audience • Eating in Restaurants • Writing in Public • Using Public Rest Rooms

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Taking Tests

B. Generalised SAD In contrast to specific social phobias, people with generalised social phobia (SAD) fear a wide variety of what may seem to be unrelated situations involving other people. However, the common theme in both the specific and generalised forms of social phobia is the fear of disapproval. The individual with SAD dreads many, if not all, situations in which there is a chance of making a mistake or behaving foolishly in front of other people. The person exhibits SAD when they feel that they are closely watched and judged by others, as in public speaking, eating, or using public facilities. This gives rise to a persistent irrational fear of situations that are perceived as threatening. The person strongly imagines that in any social or performance situation that involves facing strangers or being watched by others they will show behaviours that will be judged by others causing the person embarrassment or humiliation. The phobic stimulus almost always causes anxiety, which may be a cued or situationally predisposed panic attack. The patient realises that this fear is unreasonable or out of proportion. A common response that the person makes is to avoid the situation as much a possible. This gives rise to another term for this condition, Avoidant Paruresis (AP). The patient either avoids the situation or endures it with severe distress or anxiety. It markedly interferes with the patient's usual routines or social, job or personal functioning. This is not about people avoiding toilets for aesthetic reasons. This phobia is situationally and pathologically specific about the presence of other people and the person may not fear most other social situations. The description given in the DSM currently classifies AP as a Social Anxiety Disorder with contributing genetic, physiological, and environmental factors. There is an urgent need to examine this condition from urological and neurological perspectives to look for underlying pathologies. At present however it tends to be viewed as almost totally psychogenic in origin. However, mind over body may only be part of the problem. AP ranges in intensity from very mild, even transient episodes, in which the person can urinate in public facilities under certain circumstances, to severe, lasting and debilitating forms, in which the person can only urinate when alone at home. AP exists then on a continuum with some people having a few and some many symptoms; the more symptoms, the greater the disability and consequent social isolation. Most people occasionally experience at least some hesitancy in public restrooms, and realise that hesitancy is normal. Hesitancy ranges from a momentary delay in initiating the process to chronic and acute retention. But in people with AP any hesitancy is perceived as a failure

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___________________________________________________________ and this makes the anxiety worse, with accompanying feelings of embarrassment, shame, disgust and low self-esteem. 5.

Origins

For a person suffering from Avoidant Paruresis, the inability to use a public toilet is a problem that may have developed in early childhood or adolescence. Even in the security of a person’s home, when others are present the persona with paruresis, the paruretic, may not be able to go to the toilet and urinate. It affects both men and women; one out of ten sufferers are women. It is estimated that about 7% of the population are affected in some degree or other with this condition. This suggests that in the UK alone some 4 million people may experience the problem of paruresis with a corresponding figure of 17 million sufferers in the USA. A study of Social Phobia was done in 2002 in Winnipeg, Manitoba, and Alberta (N=1956 respondents). In response to the question "do you have fears of using toilets away from home," 9.1% said yes. The incidence is fairly high. An earlier 1997 social phobia sub-analysis done at Harvard Medical School from the 1994 National Co-Morbidity Study indicates that 6.7% of a RANDOM sample of people in the U.S. said that they have difficulty using a public toilet away from home. Other studies from the US Navy reported higher figures from failures to provide urine samples in drug testing procedures. The accepted figure of 7% is a fair representation of the incidence of this problem. Like other phobic states this problem may the result of faulty perceptions and the nature of the individual. Gardner & Gibbs (2005)2 reported to the Health Psychology Division of the BPS the personality profiles of respondents from an Internet study carried out by Gibbs. This showed that there were elements of introspection, private selfconsciousness, and a desire for attention to detail. Here was also evidence of rumination and reflection in this survey of (N=264) adult males In essence, social phobia is a fear of disapproval. In effect our internal cognitive model is out of sorts with what is apparently real. We construct reality in our heads not as it is but as we think it is. There are many factors in the personal construction of reality. Some may be due to childhood training by parents of guardians. It may also be the result of alarming incidents that are so emotionally traumatic that they leave the person damaged. Bullying in early school life had often been reported as a possible onset of this condition. Processes of suppression and repression may be major elements in casual behaviour in paruresis.

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Real World of the Individual

A. Classifying and the Learning of Social Scripts We develop an early understanding that we play a role in social processes. The young child learns that life is played out as on a stage, and that each child has to learn to act in an expected way, and often in a conformist manner, and play the role with a given set of lines. These rules are internalised in the child’s head as a set of social expectations. Social psychologists suggest that the frameworks, the stage settings, are stored as representations of reality. These are internalised as Schemata. Also stored is the way to play out the normative role, known as the Script. We have Schemas and Script for many of our everyday social roles. Our history and experiences have set us up with a social mapping in our heads that tells us the appropriate way to behave in social settings. It maps out the parameters of acceptability, and gives us the messages of the way we should behave. This is the Schema and Script of behaviour. The Schemata are the social dramas we take part in with an understanding of our personal roles, and the Script is the way we know how to deliver our lines on the life stage. In learning social scripts the child also learns about the ways in which s/he is praised or punished with regard to social or anti-social behaviour. As well as this, and another essential part of social learning, is that the child has to learn to differentiate between classes of objects. The mind seems to store classes of objects in ways that categorise them. These are the concepts we learn and extend from new experiences. The mind sets up classifications that allow one to identify one object from another, and establishes ‘test’ questions from which such differences can be identified. These test questions are the constructs by which we differentiate the classes. Some constructs are taught to us and others we learn: shape, colour ands tastes are some of the defining constructs. We learn early that bananas and apples have different shapes, textures, and colours. This is so even though we recognise them and their similarities as part of our general classification of edible objects. The major class of fruit, seen as something that is generally edible and good, contains a great variety of subclassifications. The perceptions we take of one member of the class of fruit, for example an apple, tells us it is a fruit. We then use mental ‘test’ questions, constructs, to further break down into the appropriate final sub category, for example differentiating between Canadian Mac Reds or French Golden delicious. In the West differences between types of bananas are not so well defined as in the East where many different types of bananas are identified. Eskimos have more than 25 different words for snow, but in the UK snow is just snow! Our culture defines the ways in which we label what we see.

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___________________________________________________________ The overall concept of fruit is also categorised by our ability to frame this up or down in a hierarchical manner. We can see this as a subdivision of all edible food, or a single concept that contains all types of fruit. Our experiences in the culture in which we live allow us to develop the constructs by which we make these divisions and finite identifications. In our thinking about classes of fruit we may also have personal favourites or even dislikes. So we not only store our knowledge about things but how we feel about them as an affective construct. In a similar manner the way in which different cultures perceive toilets and toilet habits is necessarily part of each particular culture. The great mistake is to assume uniformity of perceptions. Within each culture there can also be differences in perception depending on individual experiences and personal choices. B. The Real World of the Individual There is currently a continuing debate in academic circles regarding the nature of consciousness. Psychologists cannot come to a consensus opinion on the nature of consciousness, either in physiological terms explaining brain activity, or in accepting psychological concepts of mind activity as conscious thought. And certainly not in how these are related. The relationship between brain activity and the resultant feelings of subjective experience has still to be resolved. There can be little doubt however that we do represent our experiences in some personal way that is unique to us. There may be some degree of communality with what others perceive but essentially the person experiences the external world in a totally subjective and unique way. How this is done we do not know. Subjective experience, and how it regulates our activities and directs our choices, is what we are dealing with here in a very basic manner and cannot be said to be an account of why things happen but rather an explanation of how they might happen. Experience cannot be predictive of behaviour but rather provide an account for the possibility of likely behaviour derived from the psychological processes in the mind of the individual. When we are faced with a choice, we fall back on the experiences from which we have learned that, for us, represents ‘good’ or ‘bad’ choices and we may use these as exemplars. The psychological processes that operate involve many ‘mind sets’, concepts and constructs that have been formed by the experiences we have had. Some of these may be the result of social or personal conditioning. We draw on the schemata and script looking for ready-made answers. In order to explain how these operate they are often seen as separate and distinct processes. However this is not really the case, they will operate as a holistic system. When we are faced with a choice, we use various psychological processes to make our decisions as to what we think we want. These are surface considerations, but there are also many unconscious processes at

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___________________________________________________________ work. Across the board there are many similarities in these processes for each person, but each individual may use them in a totally unique way. This is the result of the special experiences that no one else has and that guide the personal choices of the individual. That is, each person may have similar comparative concepts and constructs to another person or a group, but the way in which they are developed and deployed is completely unique. The complete view that people take of reality in the external world may be recreated as an internal model; the subjective reality of that person. This unique subjective view is what is called here the REAL WORLD of the individual. This is a model of the way we interpret our experiences and perceptions. Just as an architect conceives a plan and used this to show how a building can be envisaged, so in psychology a model can help develop insights. It may also helps in explaining behaviour as the result of a variety of psychological processes involving thoughts, feelings, and even dreams It is called REAL because it exists in the mind of the person, that is, the way s/he sees the world. For that person the thoughts and feelings they have are in essence real. It is also called a WORLD in so far as it is a representation of the reality as that person sees it. People can, if asked, share the experiences they have as far as they know they exist. Normally however they act as a kind on automatic pilot guiding our behaviour. The fundamental nature of the human psyche however means that there are areas in the subconscious that influence the way we think, feel, and act without our knowledge of what is operating. So what people tell us about their experiences may only be part of the whole picture. There are three main components to this Real World model. IDENTIFICATION

ORIENTATION

ANTICIPATION

I. Identification The perception processes start with an awareness that something is going on in the external environment. This has survival value for us. We see things change and are alerted to attend to them. If primitive cavemen did not attend to the changes in the near environment they would be in danger of being eaten. Early man may have developed a strategy in relation to a new animal: “Will it eat me” or “can I eat it”. Information from the psychology of perception indicates that we seem to be programmed to attend to things that move, that are bizarre and that have strong sensory stimuli. To do this, we use all our sensory processes. After the awareness and attentional factors have been deployed, we try to make sense of what we see or hear. In order to do this we call up prior experiences to check if this external event was something familiar or something strange. So there is an act of recognition at work, matching past

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___________________________________________________________ and present experiences, in making the identification. (See Table 1 PRUBIC) From our memory banks we can also recollect if the past experience of the object or event was a pleasant or unpleasant one. Most people have recollections of toilets where the sounds, smells, and visual aspects were abhorrent. People with paruresis may also have bad memories of bullying at school or restrictions on toileting behaviours. It may also have resulted from inconsistent parental toileting training, or the lack of it. In this paper the combination of all these processes is called the Identification (or Recognition) factor. This is the first part of the process of making sense of our environment. It is clear that this operates out of the past, made manifest, or brought out through the stimuli of the present. The concepts that we hold allow us to define objects or situations in terms that are meaningful to us and related to our experiences. These may be hierarchical or restrictive in operation. Consider the concept of a toilet. It may mean different things to different people depending on the culture and personal beliefs. The concept of an acceptable toilet would be different from Western perspectives to that of Eastern or Islamic perspectives. In these the issues of seclusion, privacy and washing may mean different things in these different cultures. In general however in Western concepts of toilet we can define toilet as; A bowl-like receptacle for the body’s waste matter, with a water supply for washing this into a sewer3 To understand this definition we must also understand concepts such as receptacle, waste matter and sewer. Underlying these are other related issues. Some people may want to avoid public toilets because of fears of hygiene or smells. For the person with AP it is the feared, imaginary or actual presence of others that makes it a dreaded concept. The social identifications we make of things relates to the overall or holistic views we take embodying our constructed definitions and underlying concepts. That is we have a total view. The early experiences of the person with paruresis may also include the negative affective element as part of the concept. Bullying at school may have been part of the initial onset of AP. The object of our attention will also call up a variety of psychologically based processes that help us make a valuation of the thing that we see. As well as script mechanisms, our attitudes, our feelings, values and beliefs are all active in this process. So from these we are set to make a judgement about whether the object is ‘good’ or ‘bad’. And hence

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___________________________________________________________ our behavioural response to this. One way to see the perception process in relation to behaviour in action may be modelled as in Table 1 below. This model contributes to the understanding of information processing and behaviour changes of offers possible reasons for lasting, characteristic unchanging stable behaviour. Table 1 PRUBIC Perception Read

Understand

Belief

Internalisation

Change

Depends on being aware of, then attending to the stimulus. What we ‘see’ often depends on what we already know and believe. This relates to the information we perceive and our capacity to ‘process’ this E.g. if the language we ‘read’ is at too abstract or formal (or even in Dutch) we don’t process this well. For read consider it to be “take in information” Relates to the way in which we store and frame up what we already know. Our current mental maps focus our understanding. In some sense we can only understand what we already know. But we can modify our understanding with fresh, new fresh information Beliefs exist at different levels, from superficial to deep seated ones. Beliefs, values, and attitudes operate in similar ways. Does the information we process reinforce our existing beliefs or if not do they challenge them? This may make the person do a "double take" and review the situation. Or even reject a new view or idea. If the message is very important to us we will process this to make it part of our belief system rather than take it in superficially. The deeper we internalise this the stronger the belief will be. The effect is long lasting and may be integral part of our personality The deeper the belief system the more important it is to us, and the more it has a fundamental role to play in the control of our actions If we deeply internalise the new belief then the more likely it will be that basic behaviour will change. If the old belief is deep rooted it may make behaviour rigid and stereotypical in nature.

The identification component may also contain a set of value judgements which are unconscious but which are operating to drive deepseated psychological problems. Stereotyping is a case in point. Behaviours based on this are deep seated, internalised and resistant to change. In the person with paruresis there are many reported histories of poor toilet training and resultant adult hang-ups. Hence, in the recognition of toilets there may be deep psychopathologies. The paruresis condition is very painful as anyone who has experienced a full bladder can testify. The extreme sufferers may be so caught up in this condition that they give up work and do not stray far from the security of their own homes and toilets. They may have to resort to self-catheterisation to gain relief. This procedure can carry risks of infection. The past experiences that these sufferers identify and feel deeply

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___________________________________________________________ about relate to can cause them to perceive the public facilities in a very different light from the vast majority. The past provides pathologies for the present. A different example may illustrate. A woman was found uncontrollably crying after the theft of her handbag. It had been found in a toilet with the contents strewn around the floor. The personal distress of this was more than seemed appropriate at first sight. It transpired that she had been raped as a young girl and she perceived the episode of the handbag as another defilement. It was not so much the theft was abhorrent to her, but the sight of her personal possessions strewn on the toilet floor. This violation had caused her to recall the trauma of the rape. The rape experience had been buried deep within her mind until being forced to the surface through the theft. She had carried the burden for many years. What she identified as ‘good’ or ‘bad’ and what she avoided all of these years was in some part a result of her unhappy experiences. She now carries an aversion to public toilets based on the association of the rape and where the stolen articles were discovered. But this is not paruresis. Past histories may stay with us, lurking beneath our awareness, until some trigger thrusts them to the surface and makes us encounter further distress. In clinics that deal with problems of wetting and soiling, clinicians know the importance of early childhood events. Some of these events can make the sights and sounds of the public washroom identifiable as negative events. Paruresis makes people avoid public toilets not because of their physical attributes but of the imagined fear of others being present there. The Identification component makes use of the full sensory capacity of the individual, the range of experiences stored as a cognitive framework, and an affective element based on our likes and dislikes. It is about recognising the world as it exists for us, our subjective reality, and how we feel about this. Identification, what goes on from the past, colour memory with emotional tones. As we mature and develop the sensory, cognitive, and affective inputs from our perception of reality enriches the way we frame up the world. When we perceive something in essence we are working from past experiences. Objects are recognised physically and emotionally. We look for things that we believe from past experience are suitable and desirable and of value to us. These memories are the start of the behaviour processes. The psychological processes that develop our concept hierarchies, and associated constructs, may outline an unconscious IDEAL. These processes give us ready-made ways of seeing the world and set us up to deal efficiently with new experiences. They may also however establish rigid and narrow frames of reference in connection with

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___________________________________________________________ particular sets of circumstances that hinder our optimal living. They may establish a platform for the processes of avoiding behaviours and be disruptive of a normal life. Our past affects our present. Such may be the nature of a phobia. II. Orientation Consider however the person who requires to go to the toilet with a full bladder. In psychological terms this person has a pressing need as well as a physical one. It focuses the attention mechanisms in seeking resources for relief. Social norms, scripts and schemas, dictate that using the street or someone’s garden is not a ‘good’ thing to do. A toilet is noticed, but the smells and sight makes that toilet non-acceptable. Even if that person has rejected this toilet area aesthetically, the functional aspect of the toilet draws him to it. So the person is in some conflict as to whether to approach that facility or turn away from it. Depending on the strength of the need, the person may opt to use the facility despite reservations and negative feelings, or with some pain and distress delay relief and seeks another facility. So needs as currently experienced play an important role in the way we accept or reject the perceptions of the external world. We are drawn towards some kind of things and repelled by others. For people with toilet aversions, phobias and related psychological problems, their difficulties in the way they perceive and avoid things become understandable and why they feel as they do. Problems such as avoidant paruresis can be understandable in the light of identification and orientation components of this model. The problems of suffering a full bladder and then being psychologically inhibited to urinate in a public toilet are functions of the unconscious alerting the conscious mind to avoidance reactions. This aspect of the REAL WORLD of the individual is called the Orientation factor and operates as a dynamic force in the present. Orientation is like a steering force, we are guided by personal mind processes to approach or avoid what we see or perceive. Some people’s perceptions of an object make them approach it, whilst the perceptions of the same object by different people will make them avoid it. As we have seen above in the examples of toilet related psychopathologies, there can be conflicts or tensions set up in the mind of the person between desirable elements and undesirable elements. This is an Approach-Avoidance conflict situation. The strength of the various elements in the perception of the object will dictate the degree of conflict and the resolution of it. In AP the need to urinate leads to an Approach scenario but the Anxiety State contributes an Avoidance component. This is often the strongest force.

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___________________________________________________________ In a similar manner we can highlight other basic conflict situations and describe them as Approach-Approach or AvoidanceAvoidance. The first of these explains how a person is torn between two desirable alternatives and is placed in a dynamic situation, which results in him/her oscillating between the two alternatives. As s/he approaches one choice the factors which make it seem desirable can be weakened by the perceived desirable elements of the other, making the alternative choice seems more desirable in its remoteness. This dissonance leads to difficulty in making choices. In the second scenario the person is held between two undesirable alternatives, and if forced to proceed with one or another, chooses the one which has the least avoidance provoking factor; that is one is accepted as the lesser of two evils! If the area or psychological field is not “policed” then the person flees the situation. An important factor in the understanding of conflict and choices is the way we place a psychological value on an object or situation. That is, we endow a perceived object with an eminence much greater than any intrinsic value. Consider an object of personal sentimental value, a trinket for example. The object is worth more to us than what it might cost. We all have a favourite object that we consider of great merit and value but which another person would discard as rubbish. Each has perceived a personal, but different value in the object. Psychologists may call this the Valence value and this contributes to the dynamics of present behaviours. These psychological components of value as part of the dimensions of choice resulting in a conflict situation sets us up to accept or reject washrooms and toilets in our present environment as an act of preference based on past as well as present perceptions. We give value to one kind of toilet but not to another. We may not be fully aware of the processes of choice but it seems likely that this act of orientation is one way in which they operate. We see the results of choice! Not the processes of choice. Orientation, what goes on in the present, depending on attitudes, values, beliefs, as well as identifiable needs or wants, produces complex internal psychological processes about judging the perceived world and hence making judgements about approach or avoidance behaviours. This constructs a kind of steering force directing our behaviour. Through these processes objects get an emotional charge from the individual, the Valence Value. This dictates the degree of attraction or repulsion, as well as the direction of the pull and the dynamics of behaviour. Depending on the strength of the processes, for example the degree of attributable valence value on the object, high or low, the person will be drawn to or repelled by the perceptions of the object.

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___________________________________________________________ We approach those things we value positively and we avoid if possible those that we have a negative value for. It is in the nature of a phobia to avoid certain situations, places, or even people as a consequence of the unconscious underlying forces of vector valence. III. Anticipation The third factor in the construction of reality as a subjective perceptual experience is our thinking about future events. We may have an understanding of what we think we want to happen in the future and even have expectations of what we feel should happen. However, it must be clear that there is a real difference between anticipations and expectations. Expectations are thoughts about what we think should happen in any social circumstance. That is, we have a right to expect things from social institutions or formally established roles. These expectations in part come from our concept of what it right and proper and may be the operation of our Schemata and Script in action. We correctly expect a public washroom to be clean, tidy, and functional. The manager of that facility we expect to behave in a proper decorous manner. Anticipation however is more closely related to our personal preferences, dreams and desires about what we would like to happen. We may anticipate the washroom facilities in a major corporation to be more elegant and ‘upmarket’ than one in a cheap hotel washroom. This is so even thought there is little difference in the functional aspects of these two toilet situations. We may hope that there are extra facilities in a work environment that takes cognisance of an employee’s social and personal needs rather just the design of a functional space. This component in this model of subjective reality is thus known as the Anticipation factor embodying both expectations and the unique personal anticipations of the person. We may have both positive and negative anticipations. Often the negative anticipation is caused by ignorance and stereotyping or traumatic personal experiences. Anticipations, what we think may go on in the future have strong emotional undercurrents, not always what we expect from rational conscious processes. If we get it wrong or judge other people’s reaction wrongly then we get disappointments if our expectations are not met and we may experience a sense of failure. This can have profound implications for the reactions of others to our relational behaviour. Problems for people with paruresis may come because another person who does not know about paruresis, or who does not understand the nature of this problem may have expectancies about the way a partner, friend, or relation will behave. The problem with secrecy is that other people can never know the suffering the paruretic experiences until that person runs the risk of

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___________________________________________________________ disclosure. The anticipations of the paruretic however include fears of ridicule, rejection, and isolation. These three components of personal reality then are the foundations of how the external world is represented in the mind of the individual. This world is different for each person, so assumptions made from one person’s frame of reverence may not contain the ‘truth’ for another. The ‘world’ is different for each one. 7.

Problems for Paruretics

Mandatory drug testing is on the increase. In society today there are increased demands for urine samples. It may become a requirement of employment. This may be done to check drug or alcohol levels, or even just for a general health check up. Giving a sample under supervision is often a difficult task and an impossible one for paruretics. Often people will just change jobs rather than go through the humiliation of being unable to provide a specimen. One major problem is that the government rules guiding MDT in prisons, police, and probation services rules state that a failure to provide a urine specimen is interpreted as a refusal for which the person can be charged. In prisons this means 28 days being added to a sentence and loss of privileges.4 8.

Aiming to Pee

People with paruresis would try to get help from therapists of all sorts. As little information is really known about the nature of this problem there can be no detailed treatment based on clinical understanding. Some professional people may not know even about this condition. Many GPs were unaware of this being such a quality of life affecting condition. Sufferers have said that even those who knew about it may have been unsympathetic. Hypnosis has been tried by many paruretics but with little success. Peer-reviewed studies of various treatments for people with other social anxiety indicate an approximate rate of long-term improvement (reduction of symptoms) for somewhere between 40 and 65 percent of the study participants, depending on the study. Higher rates were reported for people who combined therapy techniques, such as cognitive-behavioural therapy (CBT) plus a support group, medication plus a support group, or all three in combination. Recent studies on CBT for social anxiety disorder indicate that the highest recovery rates happen when treatment includes exposure

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___________________________________________________________ therapy and cognitive restructuring, which consists of learning to question one’s flawed thinking and substitute healthy patterns of thinking. In paruresis, this is an essential process to promote recovery. Cognitive behaviour therapies for social phobia or SAD syndrome may help people alter the way they think, feel, and behave in social situations. This can mean a fundamental change in the way they see the world and how they feel about this. In turn, this can result in a change in the belief systems. (Table 1 PRUBIC) Several common components of cognitive behaviour therapy emphasise this. Exploration of the nature of social phobias and faulty beliefs have certain common features though individual therapists may vary in the their approach; • What people expect socially • Exploration of the nature of social phobias and faulty beliefs • Identification of needs and problems • Treatment may also include desensitisation, which is designed to help people confront feared situations in a gradual exposure to the perceived threat • Anxiety management skills • Understanding and dealing with conflict and choices 9.

Reducing Performance Anxiety

Psychological counselling in some form or other seemed to offer a cure. However, many therapists with experience of helping paruretics consider that psychodynamic and other traditional psychotherapies probably have no place in the treatment of social anxiety disorder. There must be a behavioural component in the treatments to give confidence and feelings of successes. One approach that is recommended by the International Paruresis Association and which is the basis for the many workshops run internationally is systematic desensitisation. The person is confronted with the worst fears and then is gradually introduced to the source of that fear, reducing the anxiety levels. This deals in part with the primary paruresis but not the secondary effects. One of the many problems is that therapists may not know about paruresis and that there can be two main components of this. It is suggested that there are Primary and Secondary Paruresis5. Primary paruresis is the avoidance of urination when in the presence of others in public toilets or at home at the sever end of the condition. This is the dynamic conflict outlined above as Approach-Avoidance behaviour from the Real World Model. Secondary paruresis is the guilt, shame, and embarrassment and loss psychological well being as a consequence of this. Quality of life (QoL) is not directly observable or the result of medical administrative processes such as the assessment of quality of life years. It is a subjective and affective experience and may be the product of

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___________________________________________________________ similar dynamics to those that result in the development of the Real World model of the individual's perceptual processes. QoL is a state of mind unique to any particular person. To determine the QoL for an individual we must rely on that person disclosing factors as they see it that lets them make the judgement about their perception of QoL Gardner's Quality of Life model6 suggests that there are several factors involved. The strands of QoL must be in harmony and in some state of dynamic operational tension. They all exist together just like the strands on a spider’s web. It suggests that the main anchor components all have to be in dynamic equilibrium in order for the person to feel in a state of well-being. If people are down hearted and starts to loss faith in them selves the tension that holds the web together becomes slack and so the state of excitement and joy in living goes. Some of these factors, and their opposite poles which are significant are: Self Worth Low self image

Control Powerlessness

Social integration Isolation

Self efficacy Helplessness

It is easy to see that when Quality of Life is focussed in particular about the opposing dimensions of control and helplessness then the effect is felt across the whole area marking out QoL existing at different internal levels. In the person with paruresis there is present a lot of personal negativity in relation to this condition and they start to believe that they have no control, feel socially isolated and helpless. They often report that they feel miserable and alone and that they feel others will ridicule them if they allow their paruresis to become public knowledge. Hence they will not disclose or talk about their paruresis and this give rise to the description of the condition as the Secret Phobia. The QoL model was first developed from the qualitative and quantitative aspects of a study of (N=4,5000) people with epilepsy (Gardner 1998). In another study (Gardner 1996) of people suffering from cold sores (N=2,000) similar effects were seen. Interestingly, findings from these two disparate studies revealed another common feature that may relate to the psychological conflicts of the Avoidant Paruresis. This at its simplest level is the twin but related phenomena of Imposition and Limitation. The medical condition, and in the case of epilepsy the side effect of the drugs used to reduce seizure episodes created an imposition on social behaviour. It stops people doing things. This in terms of the QoL model meant lack of full social integration and a weakening of this anchor strand, and hence a lowering of the full dynamic for QoL. For the person with AP the imposed avoidance behaviour as a result of the psychological processes associated with the primary paruresis causes similar effects. The

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___________________________________________________________ second effect, limitation, was noticed where the person for fear of possible harm (perhaps having an epileptic seizure in public) or in with cold sores sufferers the fear of embarrassment and so the person with AP may self limit their personal, social, work and recreational behaviours in being overtly self-protective from fears of being in a situation that enhances the secondary paruresis effect. This performance anxiety exacerbates the problem. Unless therapists fully understand this psychological dynamic then this may be one reason why health care is not happening in paruresis as well as it should. 10.

Help with the Problem

Until recently there was no organisation in the UK that existed from which paruretics could get help and advice. In the USA there is the International Paruresis Association (IPA), which offers support and advice to paruretics. Now in the UK there is a recognised charity known as The United Kingdom Paruresis Association (UKPA)7 founded by members who were willing to break the shameful silence and speak out about this condition. They can offer advice on the kind of treatments that from practical experience are most likely to be successful and where sufferers should go for help. They also run a website where people can exchange their stories and learn about how others are coping. They organise regional meetings and workshops where paruretics can get help with the problem. The website has lots of stories about people starting to learn to cope with AP. The most common responses have been, ‘I did not know there was a name for this’ ‘I thought I was alone’ ‘I am glad to have found this site and share my experiences’ Through this contact many have learnt to break out from the silence and start to tell others thus breaking the cycle of the phobia. As yet however there is no real cure, just a long painful battle, sorting out the mind games of many years. Because it is such a long-standing condition, in some people lasting 40 years or more, cures can’t be affected overnight. But there is progress when people are willing to work at this and day-byday break down the steps that lead to failures. Some paruretics have mild symptoms and have occasional successes, but others find it impossible even in the best of conditions. For these extreme cases relief is a matter of resorting to self-catheterisation. A procedure, which in the ill informed, may run risks of injury or infection. Through the UKPA sufferers are advised to seek professional advice through a GP referral to a consultant urologist. The first stage is to ensure

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___________________________________________________________ that there are no organic or physical reasons for the paruresis. Advice is then given on how to obtain catheters and how to use them. In general however the more people that understand this problem and deal with it sympathetically the easier it will be for paruretics to overcome this secret phobia and live a normal full life. Better understanding of the psychological processes at work in this condition has to be arrived at through research and further study. Only then can the performance anxiety for millions of sufferers can be reduced and the aim to pee freely can be achieved.

Notes 1

Diagnostic and Statistical Manual of Mental Disorders, 5th ed., s.v. “Social Anxiety Disorder”. 2 A.P.W. Gardner, R. Gibbs, and A. Smith, “Can't pee - Won't pee. Researching Paruresis - The secret phobia,” Proceedings of the Division of Health Psychology conference Coventry. Sept 2005 (in press) 3 Chambers dictionary (1998), s.v. “toilet”. 4 Gardner and Gibbs (2005) 5 Christopher McCullough, “Free 2 P: A Self-Help Guide for Men with Paruresis,” self-published work, 2000. International Paruresis Association. 6 Alex Gardner, “Living with Epilepsy Quality of life as a dynamic process.” Health Psychology Update (1998): 17-21. 7 United Kingdom Paruresis Association: Registered Charity. www.shybladder.co.uk

Author Alex Gardner Insight Inquiry Research Consultancy Consultant United Kingdom Paruresis Association Member Advisory Board International Paruresis Association

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Asylum Seekers in Australia: Turning Repression and Stress into long-term Anxiety and Depression Harold A. Bilboe Abstract Since the mid 1980s, Australia has had a policy of mandatory detention for asylum seekers arriving on its shores without prior recognised refugee status. Many of these people then spend several years in relatively inhospitable and isolated detention centres, denied access to normal social interactions and community life. Despite being labelled as “illegals” and “possible terrorists,” more than 90 per cent of them have been granted refugee or temporary refugee status. Most individuals arrive with some form of trauma but with a sense of relief to be free from the repressive regimes in their homelands, but this soon turns to anxiety, depression and major depression, as the screening process continues without any apparent resolution. Their already vulnerable condition deteriorates into bouts of recurrent anxiety, severe depression, and selfharming behaviours. Once released, the long-term effects of detention result in ongoing symptoms of depression and anxiety. While detention serves a political end, the cost to individuals and the community is I believe clearly too high for we are creating long-term social and mental health problems which will require extensive support and counselling. This paper explores the question of trauma and traumatisation during the detention process and raises the question whether the detention process is a form of psychological torture? 1.

Brief History

During the 1980s, in response to an increasing number of asylum seekers from China, Cambodia and Vietnam who arrived in Australia by plane and boat, the Australian Government began to attempt to restrict refugee access and rights. In the late 1980s, Australia opened detention centres, euphemistically known as Immigration Reception and Processing Centres (IRCS), mostly in inhospitable and isolated parts of Australia, on Commonwealth properties, which were outside of State jurisdictions and laws, including child protection laws. In more recent years, asylum seekers have arrived mainly from the Middle East and the Government has responded by refusing asylum to people but granting them “temporary protection visas,” creating an underclass of people who cannot return to

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___________________________________________________________ their home country but who have no rights of citizenship, permanent settlement or reunion with their families and no rights to access welfare and educational opportunities. From 1997, Australia has indefinitely detained asylum seekers while their refugee applications were processed, it also toughened the assessment, review, and appeal processes, banned family reunions and abolished permanent visas. In August, 2001, in the lead up to a Federal Election, the Government refused to allow entry to a Norwegian cargo ship which had rescued 438 asylum seekers off isolated Christmas Island as they tried to sail to Australia in an un-seaworthy boat from Indonesia. Prime Minister John Howard announced that no asylum seeker aboard the Tampa would set foot on Australian soil. The Prime Minister, Mr Howard, insisted that: ‘I believe that it is in Australia’s national interest that we draw a line on what is increasingly becoming an uncontrollable number of illegal arrivals in this country’, and stated that those rescued by the Tampa would not be allowed to land in Australia. 3 The Government introduced the so called “Pacific solution” and forcibly directed asylum seekers to neighbouring Pacific Islands, such as Nauru, Mannus Island and Christmas Island, away from any public and media scrutiny. The Tampa Crisis decision tarnished Australia's international image as a humanitarian nation, but it revived Mr Howard’s political fortune and the government was re-elected. The government also excluded certain territories from Australia’s migration zone, including Christmas Island, Ashmore and Cartier Islands, and the Cocos (Keeling) Islands. This meant that unauthorised arrivals to these territories could not apply for a visa, except by ministerial discretion. The Bill has the effect of expanding the definition of ‘excised offshore place’ to include the Coral Seas Territory and certain islands that form part of Western Australia, Queensland and the Northern Territory. During the “Tampa Crisis” period, 350 people drowned off Indonesia, in October, raising further questions about how much the Australian government knew about the sinking and its lack of assistance. 2 As of October 2002, 200 people processed on Nauru or Manus had been allowed into Australia, most on three or five year temporary protection visas. The majority were women or children with family in Australia. A further 194 people from Nauru and Manus had been accepted by New Zealand, and eight refugees had been resettled in Sweden. For a number of political reasons, Australians have been told that they face a “tidal waves” of refugees, but in reality the numbers remain relatively low. Boat people numbers diminished in the 1990s to 300 in 1997-1998 with a new peak in 1999/2000.3 Even the numbers arriving by

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___________________________________________________________ air decreased between 1998 and 2000. Between 1998 and 2000, 8000 asylum seekers were apprehended and detained, for periods of up to 12 months and most them were later granted residency, albeit on a temporary basis. In contrast, European countries and the United States receive thousands more asylum seekers and even Canada, to which Australia often compares itself, accepts three times the number of asylum seekers during the past decade than has Australia. Furthermore, the government chooses to ignore an estimated 50,00 illegal immigrants in the country, mostly from the United Kingdom and the United States, who have come legally and have stayed illegally after their permits have expired. Where Australia was once regarded as being a leading advocate for refugees, and human rights, it is now considered to be a pariah in its treatment of refugees and asylum seekers. And while it has denied basic rights to people detained, it has ensured that those who are released, will have a significant cost impact on the community because of their fragile emotional and psychological state – which their detention has caused and continues to aggravate. Australia is now the only country in the world, which has a mandatory, non appealable detention process. 2.

Locations, Place and Life Inside

Until recently, asylum seekers, who the Government now determined were illegals, criminals, terrorists were held in isolated, outback centres, such as Woomera in South Australia and Port Hedland and Curtin in remote Western Australia. These centres are adjacent to or in desert areas, many, many kilometres from major town centres and with limited infrastructure and facilities and not only for asylum seeker. For instance, staff at Curtin centre lived in demountable buildings, known as Dongas, with approximately 8 rooms each two by three metres in size with one door a bed table, cupboard and a window with an air conditioner in it. There were separate shower and toilet blocks. By contrast, staff at Woomera lived in comfortable housing in the Woomera village. Woomera, where I worked for almost 18 months, was originally a joint defence testing facility with the United Kingdom. During the 1950s, atomic bombs were tested in the area. It was this remoteness and isolation, plus the fact that there was still a small township with empty homes which could be used by staff, which made it desirable and cheap to establish as a refugee centre. The centre was constructed around a jail like design. Asylum seekers were housed in large buildings, with no shade, rocky ground, 10 metre high palisade fences and razor wire – where temperatures during summer reached up to 50 degrees Celsius. Initially, the housing units did not have air conditioners. The centre was run like a jail and many of the staff came from a private jail background, which

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___________________________________________________________ naturally meant there was conflict with staff that came from a community health and medical background. But in reality, people in Australian jails were better treated, had determined and or fixed sentences, had the possibility of release and were granted educational opportunities and visits from community members and families. Refugees, on the other hand, had very limited educational opportunities and minimal recreational facilities available, had no release date, had limited access to translation facilities and were separated from community visitors. The effects of prolonged detention on children were particularly pronounced. Long-term detention often means that they miss out on formative influences in their development. This includes consequences for their health (including mental health), education, and their ability to develop skills and knowledge in line with social norms or to develop in a normal environment. While it is necessary to check the identity, health and security status of new arrivals – especially those without appropriate documentation - these checks can be completed within thirty days – as they are in Britain. Beyond the time period required to conduct these checks, ongoing mandatory detention is unnecessary. Woomera consisted of several compounds: an arrival compound which had Hessian wall screening to stop interaction with other detainees, then a progression of compounds as detainees went through a series of processes, mostly being screened out in that they had not specifically requested asylum in their initial interview. Of course, no one had told them they had to use “magical phrases” such as “I wish to request asylum or protection”. If you were screened out, it could be three to six months before you had another interview with an immigration officer. All documents were provided in English, which few could read, so most had no idea of what they were reading or signing or what was happening to them. The interpreters thus increasingly became involved in the explanation and translation of documents, as opposed to therapeutic interviews and counselling sessions. At Woomera, there was a compound for high risk detainees. Initially this compound was called Oscar but later changed to Sierra. Sierra Compound was for those people who had been rejected and identified as potential behaviour risks due to reactive behaviour, threats to self-harm or acts of self-harm, yet the majority of these detainees, while I was there, did not engage in self-harming behaviour. It consisted of male detainees, when I first arrived, but later the immigration department started to place families in the compound. On one occasion a family with two teenage daughters were placed there; the girls never left their room during the whole time they were in the compound. They were released after a number of months after their father volunteered to go home, rather than subject his daughter to the ongoing traumatisation. He told me at the

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___________________________________________________________ time: “If we go back at least they will kill us quickly,” compared to what he perceived a slow death in Australia. He was deeply distressed by what he had put his family through, when his dream had been to start a new life. This was a family, who had come to the nearest Christian country and had been rejected as being “Christians of convenience” by immigration. 3.

Psychological Issues and Detainee Numbers

Being employed at Woomera was not my first experience in working with refugees. During the 1970s and early 1980s, I previously worked with “boat people” from Indo-China and am trained in trauma assessment and trauma counselling. At Woomera, I was the first psychologist employed at Woomera, although it was part of the then Department of Immigration and Multicultural Affairs (DIMIA) contract to provide psychological services. I was employed on an 80-hour a fortnight contract, but worked on average 140 hours. However, even in the extended hours I worked, I was simply not able to attend to the needs of all the detainees. Initially there were about 1500 detainees and at the time of my arrival I was thrust into an investigation of alleged sexual abuse of a young male by his father and other males. These allegations were based in part on statements by officers that homosexual acts amongst Muslim males were the norm and that “pretty young boys” were shared around. My investigations found no substance to the allegations but revealed issues regarding jurisdictions and mandatory reporting of child abuse or alleged child abuse to the appropriate authorities. I was advised that because this was a “federal” jurisdiction there was no requirement to notify the state or territory authorities. A subsequent inquiry by a Commonwealth officer also found no substance to the allegations and raised the question of jurisdiction and mandatory reporting. 4 This inquiry led to agreements between the States and the Commonwealth to facilitate mandatory notifications. However, the State and Territory authorities had no authority to intervene or remove children from a Federal Detention Centre, so little was achieved, other than superficial notifications of concerns. On average, I was having more than 100 consultations a week. For example, the statistics for October year 2001 for a psychological team of three (two psychologists and one intern) was 764 asylum seekers seen, 15 self-harm events: cutting, head banging, 5 suicide attempts, 2 hunger strikes and 1 anxiety/ panic attack In addition to this, I was responsible for staff counselling and reviewing high-risk inmates. High Risk Inmates were those who had selfharmed or threatened to self-harm. Some of these people (the most severe) were placed in isolation units that consisted of four jail cells in the township of Woomera that had been built in the 1930s. They had no

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___________________________________________________________ external windows and a 12 inch by 12 inch metal square with holes punched in it, as a viewing hole. They were allowed into the exercise area once a day or as appropriate, depending on their level of risk. On one occasion, a detainee was held naked in one of these rooms with a “suicide” mattress and a canvas sheet (to prevent any attempt at self-harm). He was kept like this for three days, despite objections from medical and allied health staff. Dealing with 100 people a week, meant that therapy was very solution focussed and issue related. There was little opportunity to engage in psychotherapy or true cognitive behaviour therapies, trauma therapies, thus leaving traumatised people untreated, because of the on-going exposure to trauma and traumatic events, such as riots, attempted suicides, self-harming. While some detainees, including children, experienced trauma before they were held in the detention environment, the detention environment at the WIRPC was in itself traumatising. This trauma came primarily from: exposure to the violence committed during riots on others and the severe self-harming behaviours of others; being subjected to this violence; the harshness of physical environment; uncertainty as to length of detention and outcome; and vilification by the government. Detainees had access to communal TV and radio news reports, and newspapers. Later in my time at the WIRPC almost all of my work hours were taken up with dealing with people who had self-harmed, or attempted suicide, which left no time for treating other people who required counselling. During one period of unrest and riots, staff worked 36 hours straight and the use of water cannons, tear gas, to subdue detainees became an increasing occurrence. The high numbers of self-harming incidents left many staff vulnerable and traumatised. Children also witnessed increasing numbers of self-harming behaviours and attempted suicides, has well has demonstrations and riots, witnessing these upheavals and the interventions by officers to restore order. These officers would be dressed in black riot gear, which encompassed a black helmet, batons and shield, full body (black) armour and boots, dressed thus moving through the compounds in lines three deep and forcefully removing and subduing individuals. This same pattern of behaviour and dress on a smaller scale was used in the early hours of the morning to remove identified individuals who were perceived/deemed to be troublemakers, and whose visa applications had been rejected. These raids usually occurred between 3 and 5 am in the morning causing major trauma to women and children in particular. For some of the detainees this replicated memories of family members being forcefully removed from their homes, never to be seen again or later to be found to have been tortured and executed, hence my belief that these events led to the re-traumatising of many of the detainees and particularly children.

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___________________________________________________________ 4.

Effects on Children and Adults

There were numerous effects of these traumatic experiences on the children. These included withdrawal, generalised anxiety, nightmares, bedwetting, serious sleep disturbance and loss of appetite. As time progressed, incidents of self-harm amongst children increased. Especially amount the un-accompanied minors. The response to the high levels of trauma to which children were exposed changed from being withdrawn to self-harm. By the time I left, self-harm was almost universal amongst unaccompanied minors. In one incident, 14 unaccompanied minors, as a group, stitched their lips in protest to a “rumour” that they their applications for refugee status had been rejected. This occurred when a DIMA officer “representative” visiting from Canberra, in a meeting, told them that they should consider returning to their country of origin. Similar comments to this led to a major 36- hour riot in 2001 where 14 buildings were set alight and razed. A number of detainees significantly self-harmed during this riot. Lip stitching, cutting (self-harm) and refusal to eat, were the only way many could express their utter despair and their final attempt to halt being dehumanised. However, the government claimed that it was manipulative behaviour designed to blackmail the government into giving people visas. The then Immigration Minister Philip Ruddock consistently denied that deep depression led to self-harming behaviours and suicide attempts. And he once stated that in his opinion depression was not a mental illness. 6 Amongst those children in detention with their parents, the main problem was loss of appetite or a refusal to eat. There was no evidence at all that children were being starved by parents, although this was alluded to by politicians. Politicians also claimed that parents held children down and stitched their lips. I saw no evidence of this and subsequent inquiries by both Human Rights and Equal Opportunity Commission and the South Australian Government found that these claims had not been supported by evidence. Parents may not have been going to meals because of loss of appetite or because they were bedridden with depression, but children would be taken to meals by others where possible. Often, they would ask friendly staff to take their children for meals. Detainees were not allowed to cook or have meals, milk or yoghurts in their rooms. They were allowed water and drinks and biscuits, which could be purchased from their personal funds (if they had any). Women detainees had to ask mostly male officers for sanitary pads when menstruating, a humiliating experience for them. Children also witnessed riots, suicide attempts and the depression and stress of others, and often their parents could not protect them from witnessing the events nor were they able to comfort them. Two types of

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___________________________________________________________ behaviour, described by The Family and Youth Services (FAYS), as part of the Department of Human Services in South Australia FAYS, and relevant to the asylum seekers in detention with respect to emotional abuse concerned: isolation - cutting the child off from normal social experience, preventing the experience of interpersonal skills and disallowing spontaneous fun and enjoyment; and corruption – teaching the child socially deviant patterns of behaviour. The Woomera detention centre, we found out, was a breeding ground for those types of behaviour. As well as family children the unaccompanied minors from Afghanistan were particularly susceptible to emotional abuse. With no family support they easily lapsed into a despondent state. According to concerned leaders in the community the children had committed no crime and it was a breach of the United Nations Convention on the Rights of the Child ratified by Australia in 1990. There was a high level of traumatisation with features of acute anxiety and depression amongst children at the WIRPC. There were high levels of early onset of Post Traumatic Stress Disorder (PTSD) symptoms apparent amongst child detainees, especially the unaccompanied minors who had minimal parental and family supports. Schooling was provided on a minimal basis and the teachers worked hard to provide appropriate teaching within the limited resources made available to them. It was not school according to Australian standards. Between 2000 and 2002, children were not allowed into the town and all schooling was conducted in the centre. It was not until late 2001 that staff were able to organise excursions into the township to the park and on one occasion to the movies. Families, as a group, were not allowed. Wives with their children could go but their husbands were forbidden to leave. Older children were allowed to go without their parents. It was believed that by keeping one family member in the centre would reduce the risk of absconding. The township itself had numerous empty houses which could have been used for housing families. Despite repeated calls for children and families to be moved into these homes it was not until late 2001 that the Government allowed, on a trial basis, the accommodation of women and children. However, their husbands had to remain in the detention centre, about four kilometres away. This was a tokenistic effort by the government to reduce public outcry about children in detention. Vilification by government was another form of trauma added to the people, who were uncertain as to the length of time they would be detained and of the final outcome and this created a new from of stress; that of stress associated with perceived future events. Following continued pressure from the public, the United Nations, and other advocacy agencies and leaked documents, several

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___________________________________________________________ inquiries were conducted and a Human Rights and Equal Opportunity Commission Inquiry was held into Children in Detention.6 This inquiry, produced for the first time, extensive publicly documented evidence from witnesses about the conditions and environment in which children were being held. The inquiry found the longest a child had been held in detention was five years and five months and at that time, 50 children had been in detention for more than two years. The Federal Human Rights Commissioner, Sev Ozdowski noted that Australia's treatment of refugees in detention centres was the harshest in the world.7 And children are still being detained. As at March this year, 93 children remain in detention around Australia and on Nauru and Christmas Island.8 Government policy has prevented media reportage of conditions on Nauru and Christmas Island and the Government has also up until very recently, refused access to refugee advocates and support groups to visit Nauru. The main stumbling block for any therapy for detainees was the inability to change the abusive environment in which they were being held. Even if you could identify the problem and provide counselling or medication, you could not change their situation which was the basic cause of their problem. 5.

Long Term Effects

A range of PTSD symptoms consistent with past events were demonstrated and all of these fall within the DSM-IV criteria for Trauma. But health practitioners also noted what I termed some “new” forms associated with current or future events. These are specific to fears associated of present and future and prospects of being detained “forever” or being “sent back”, night terrors about the present and the future; withdrawal from social interactions associated with fear of abuse and “real/imagined or unrealistic fears”. There was stress associated with perceived future events and overall there was a noticeable deterioration in interpersonal interactions within families. The long-term implications of this type of existence are worrying and it should be worrying to government policy makers. Overseas studies consistently report that displaced people are at a high risk of PTSD9 while an Australian study, revealed that of people who attended the Sydney Asylum Seekers Centre, one-third exceeded threshold scores for depression, a quarter for anxiety and 40 per cent for PTSD. A later but small study of 33 participants at the Villawood Detention Centre in Sydney, found that only one of the 33 did not have depression at some point in their detention.10 Rather than assisting people already traumatised, detention policies exacerbate pre-existing conditions and undermine people’s ability to recover. Disempowerment is a form of torture and the

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___________________________________________________________ demonisation of detainees is also a form of torture. Continuous attacks by conservative politicians, talk-back radio hosts, journalists and think-tanks have led to the deliberate creation of public opinion hostile to asylum seekers. The use of the words, such as “queue jumpers”, “illegals”, “economic refugees”, “criminals” and “terrorists”, and often lies and distortions, allows government policies to continue to be exercised with impunity, although they are inconsistent with international human rights agreements such as the Refugee Convention. (Bilboe 2001; Piper. 2002; Glendenning et al. 2004; Manne 2004) Asylum seekers are very aware of these descriptors and resultant community feelings towards them. Since most of the detainees are found to be genuine refugees, then the impost on future health and medical and social needs of these people should be considered, once they are released. 6.

Problems Caused on Release, Lack of Support

The long-term prospects for the mental health of asylum seekers, some of whom have been held for up to four years, has been impeded by governmental policies which come into effect once they are released from detention. The Australian Government has introduced Temporary Protection Visas, which I consider to be another form of cruelty towards these people. More than 8000 people who have been recognised as genuine refugees are living in limbo on Temporary Protection Visas and of course, since these visas are temporary, they can be revoked at any time and the government keeps this hanging over their heads like the sword of Damocles. Temporary Protection Visa holders have few rights and the restrictions on them are a way of effectively encouraging them to consider returning home.11 They are ineligible for a range of social security benefits, they are excluded from tertiary education due to the imposition of full fees, they are not eligible for English language programs, (compared to permanent protection visa holders who have access to 510 hours of English language, and access to translation and interpreter services) and have no access rights to migrant education resource centres. They have no right to family reunions, they have limited access to employment because of the limited nature of their visa and usually poor English skills and they have no right to Commonwealth funded employment services. They may access torture and trauma services but the waiting list is about 8 months. They have no right of return if they leave the country and we have had the tragic story of a man whose children were drowned en route to Australia and he was not allowed to go to Indonesia to comfort his wife. And on top of all this, they are provided extremely limited access to housing assistance, which must be picked up by State funded

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___________________________________________________________ organisations. Obviously with reduced English abilities and the lack of referees, they are generally barred from accessing the private rental market. Asylum seekers in the community on Temporary Protection Visas receive less than $33 per week, per family. The Federal Government then is pushing care and maintenance of these people onto State Government, community aid and religious organizations, thereby hiding the true cost of these temporary protection visas. But the draconian treatment metered out to these people once they are released, continues their mental anguish and stress, and further contributes to long term depression, anti social behaviour of young people – which surely adds to the cost of the country’s health bill - all for political and ideological reasons. More recently, many people on temporary protection visas have been asked to reapply for a continuation of their protection visas, exacerbating already stressful existences. The government has also coerced asylum seekers to return to their homelands in exchange for about $2000 in setting up costs. Mental health professionals are seeing these people and treating them for depression, which is likely to be a long-term problem. More recently, some asylum seekers have sought permission to return to the detention centres, because of the difficult situation in which they find themselves outside the razor wire. Some refugees are also taking legal action against the Federal Government for traumatic injury sustained by themselves or their children during their detention. In October 2003, the first case against the Government by a child asylum seeker, seeking damages for pure psychiatric injury was filed in the common law division of the New South Wales Supreme Court. The causes of action pleaded are negligence and trespass to the person.12 Asylum seekers are also writing books about their experiences which provide a gripping insight into life in detention centres. These letters tell the heart-rending perspective of people who considered Australia to be the closest Christian or free country. 13 While concerns about the effects of long term detention are being raised increasingly by public figures and some politicians, and the Government is making constant changes to centres in the wake of complaints, the most immediate question that Australians should be asking themselves individually is whether mandatory detention in such isolated and isolating circumstances and the imposition of harsh visa restrictions, makes us guilty of condoning psychological torture over sustained periods of time.

Notes 1

2

Transcript of the Prime Minister, the Hon. John Howard, interview on Radio 3AW, Melbourne, 31 August 2001. Tony Kevin, A Certain Maritime Incident: the Sinking of SIEV X (Carlton, Victoria: Scribe August, 2004). The subsequent conviction

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___________________________________________________________ in a Brisbane court of Khaleed Daoed, a 37-year old Iraqi man, for his role in organising the doomed SIEV X voyage, also renewed questions about Australia’s role in the tragedy. 3 Australian Immigration Department. Recent Humanitarian Statistics. . 4 Philip Flood Inquiry into Immigration Detention Procedures, Report 27 February 2001.4. Six Staff Injured as Damage Bill at Woomera Climbs to $2 million, DPS 59/200119 December 2001, (11 February 2005) 5 Australian Broadcasting Corporation, Lateline, 7 May 2003. 6 Human Rights and Equal Opportunity Commission, Inquiry into Children in Immigration Detention 13 May 2004. 7 Heather Gallagher, “Refugee treatment the world's harshest: Ozdowski”, 10 October 2003, (11 February 2005). 8 Children Out Of Detention, (12 March 2005)< http://www.chilout.org>. 9 R. F. Mollica, K.McInnes, C. Poole, T. Svang, “Dose effective relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence,” British Journal of Psychiatry 178 (1998): 482-488. 10 A. Sultan, K. O’Sullivan, “Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account,” Medical Journal of Australia 175 (2001):593-596. 11 Temporary Protection Visa Education Kit (12 March 2005) <www.amnesty.org.au/__data/ page/826/01-TPV_Education_Kit.pdf>. 12 Rebecca Gilsenan, Claim by a Child Asylum Seeker against the Commonwealth and Detention Centre operators for psychiatric injuries, APLA National Conference. October 2004. 13 See Michael Leach and Fethi Mansouri, Lives in Limbo: Voices of Refugees under Temporary Protection, (Sydney: UNSW Press, 2004); and Meaghan Amor and Janet Austin, eds., From Nothing to Zero: Letters from Refugees in Australia's Detention Centres. Footscray, Melbourne: Lonely Planet Publications, 2003.

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Author Harold A Bilboe is the Senior Regional Psychologist for the South-East Division of the New South Wales Corrective Services Department, Goulburn, Australia. He also conducts a private practice in Canberra, ACT. He has worked with refugees for more than 20 years.

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The Hospital Clown: A Cross Boundary Character Tom Doude van Troostwijk Abstract In barely 20 years, the hospital clown has become a worldwide phenomenon. Why is it, precisely, that the figure of the clown provides so much added value to the well-being of children particularly, who are dependent on medical care? In this chapter, we want to examine the proposition that care as a system prevents the Paediatric patient from fully being a child. Real and imaginary boundaries make it difficult for the child to be itself and - even more - to remain itself. “Probing the boundaries” is essential, but not sufficient, in the business of hospital clowns. To open the borders, to break through the boundaries, if only for a split-second: that’s what it is all about. 1.

A Short Introduction to the History of Hospital Clowning

In the mid 1980s Michael Christensen started the Clown Care Unit (CCU) of the Big Apple Circus, New York, USA. It was the start of a phenomenon that has since spread all over the world. Being a professional clown and artistic leader of the Circus, Christensen was confronted with severe illness in his family. He discovered the power of clowning in the context of the hospital, in the sense that it contributes to the human dignity of patients in a highly technologically dominated environment. It should be noted that prior to the CCU, Patch Adams, a medical doctor, introduced the red nose into the hospital. Soon after, the activities of Michael Christensen and Patch Adams started to attract attention, both in the US and abroad. In 1988 Time magazine published an article about the work of the CCU. At that time Caroline Simonds, who worked for the CCU, moved to France and started le Rire Medicin, becoming the first hospital clown organization in the old world. The article in Time aroused the interest of Princess Stéphanie zu Winditz - Graetz. She studied the work of Christensen in New York and back in Europe – started up hospital clown initiatives in Austria, Belgium, and Germany. These groups received the name ‘Cliniclowns’. A similar thing happened with the Dutch organization, established in 1992, although the connection with princess Stéphanie was never very intensive. At the start of the 1990s, two brothers - Jan and André Poulie started an organization in Switzerland carrying the name Theodora, in remembrance of their beloved mother.

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___________________________________________________________ During the nineties hospital clown groups sprang up in a number of other countries, such as Sweden (Clownronden), Italy (Soccorso), Hungary (Piros Orr), Spain, Romania, Brazil, Canada, the UK, etc. Surfing the internet in 2005, I found around 45 organizations, large and small, in more than 30 countries, dealing with hospital clowning all over the world. Currently, the three largest of these (measured by budget, number of clowns, and the number of hospitals in which they perform, when a comparison is made taking the relative size of the respective countries into consideration) are the Dutch CliniClowns, the Austrian Rote Nasen, and the Swiss Theodora organization. Both Rote Nasen and Theodora operate outside of their own countries as well. From its inception, the work of hospital clowns has been rather intuitive. The artistic viewpoint dominated. Clowning’s long history was reflected in its practice in the hospital. Publications on hospital clowning were descriptive rather than analytic. Case studies about the situation in Berlin, among other places, were published 1, though relatively little empirical research has been done yet. Dr. Bernie Warren, (University of Windsor, Ontario) being both a researcher and a hospital clown himself, has done the most work so far. In Sweden, a longitudinal research project (‘Salut’) has recently started up, aiming to analyze the impact of hospital clown work on children, parents, hospital staff, and clowns over a period of three years. Results will be published in 2007. In this very short overview it is necessary to mention that almost all hospital clown organizations are of a charitable nature. This means that their costs are not covered by commercial activities or by the hospital (there are some exceptions), but by the general public, including business. However, the extent to which this happens differs enormously from country to country. This knowledge provides us with the insight that hospital clowning may be considered as a translation of a societal need. Recent research in The Netherlands underlines this assumption. Respondents mention the following motivations for providing financial support: a sense of injustice, feelings of guilt, social responsibility, and a desire for solidarity and giving meaning to life. Another common aspect is that in almost all hospital clown organizations around the world the sick child in hospital is the main target group. Some organizations, however, also work for the elderly (especially geriatric patients). A number of organizations also perform for mentally or physically disabled children, as well as for children that are being cared for at home. CliniClowns Netherlands is the first and only organization to introduce successfully the concept of webcam clowning allowing it to reach substantially more children at any one time.

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___________________________________________________________ Hospital clowning has become a widespread phenomenon in the world. Therefore, it is necessary to know more about its background. In the following paragraphs I will elaborate on the various themes mentioned above. Firstly, I will make some remarks on the situation of the child in hospital, or being cared for at home. Secondly, I will describe what is typical for the hospital clown and why he is able to achieve results 2. Thirdly, I will make some more remarks on the charitable character of hospital clown organizations. Lastly, I will try to peek into the future and make some recommendations. 2.

The Hospital: A Limiting System

What is the impact on a child, when admitted to hospital or has to stay there for an extended period of time? The hospital – and all medical institutions in a broader sense – could be regarded as a system. It is the primary aim of this system to cure and to nurse the patient. The child encounters a rich tapestry of different professions and various groups. To name but a few: specialists and internists, nurses, pedagogical services, psychologists, instructors, officials, porters, cleaners, visitors such as family and friends, and spiritual carers. It is striking to note that the hospitalised child – leaving aside visitors - is engaged mainly by ‘experts’. Those relations are therefore, consciously or not, coloured by the ‘expertological regime’ 3, as the humanist philosopher Harry Kunneman called it. Kunneman, who was a student of the famous Jürgen Habermas, distinguishes, just like his teacher, between the social environment and the system. The environment is the social sphere in which people shape their private lives: the family, a circle of friends, and so forth. The system concerns relations between people which exist to serve clearly defined goals, or because of scientific or economic labour relations. According to Kunneman, the ‘expertological regime’ is the link between the system and the social environment. We allow our daily lives to be determined by what ‘experts’ proscribe or advise. Those experts have expertise because they ‘learned’ in the system. The child in hospital, too, is profoundly subjected to the demands of such a ‘expertological regime’. After all, the patient in hospital is exclusively surrounded by people ‘who are knowledgeable about something’. The hospital is inhabited by professionals. The child is surrounded by theories and practices that it cannot understand itself, but which are geared towards its well-being and health. All too easily, the child in hospital becomes ‘a case of…’ There is no malicious intent on the part of the medical or psychological class, and neither can this be attributed to the generally extremely humane and child-focused attitude of the staff. The reason for this phenomenon is actually very simple: if the patient hadn’t been ill, he wouldn’t have ended up in hospital.

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___________________________________________________________ Systems exist by the grace of boundaries. The one thing stands in opposition to the other. Boundaries and limitations put everything in a set place and make the whole manageable. Boundaries play a role in all systems but are for practical reasons even more discernable in the context of a hospital. A child that is forced to remain in hospital for an extended period of time is cut off from other social systems, which it was used to live in and live with. Those systems, too, are delimited by specific ‘boundaries’. A school-system is governed by a different set of rules and boundaries than a family or the football club. In normal conditions, a human being is a ‘system hopper’: he alternates between systems and precisely because of that flexibility he experiences a large part of his freedom. Most certainly, an extended stay in hospital carries the risk that the child is absorbed into just one environment, which causes ‘alienation’ from all other social systems and as a result from its own social environment, and in the end even from itself. 4 It isn’t difficult to imagine all kinds of boundaries which confront the child in hospital, either in reality or in the child’s imagination. Not being allowed to, or able to, get out of bed. Not being allowed to leave the hospital or even the ward or room (for instance, in the case of children in isolation rooms). Having to eat food you don’t enjoy. Having to allow doctors or nurses to administer injections (which equal literally entering your body without your request or consent). Living according to timeschedules and life-rhythms you are not used to at home. Having to follow medical procedures (in the best case scenario you are asked whether you are willing to cooperate, but this is just a rhetorical question; there is no room for the answer you’d prefer to give, which is a resounding No!). And you have to endure all this whilst being continuously threatened by the disease, which is sometimes even a life-threatening disease, on which everyone and everything seems to be focused. After all, institutions of care are primarily concerned with illness, to which the patient is subordinate. Even those who do not represent the ‘expertological regime’, such as parents, family, and friends, reveal themselves as quasi adherents to the system. ‘Just do as the doctor tells you to and everything will be all right’ is an often heard and certainly well-meant argument. Visitors ‘from the outside’, too, are without fail first and foremost interested in the state of affairs with regard to the illness. In a system of care, in which everything is concentrated on the disease or handicap, nothing much is noticeable, generally speaking, of a holistic approach to the patient, by which is meant the understanding that a child is first and foremost a child and its illness or handicap is only a part of that whole. The child, therefore, generally has no choice but to adapt to the circumstances, especially in cases of longterm or chronic care. The most pronounced example of this is when the child adopts the language of the system, of the ‘expertological regime’ (the family often does the same, by the way). Who has ever conversed

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___________________________________________________________ with a twelve year-old cancer patient no doubt recognises that phenomenon from personal experience. 3.

The Essence of Hospital Clowning

A. Key Elements of Clowning Clowns are of all ages and cultures, even though their names may differ and they express themselves differently. Clowns continuously adept to their environment and their era, and develop within them. In every era and location, the concept of the clown is shaped in a unique way. However, cultural anthropology has discerned the quintessential features of the ‘clown’-phenomenon in every culture in every age. Cultural anthropologists maintain to find these in the ‘trickster’ 5, which is a wellknown character in various cultures. The trickster is “a character which distinguishes himself by wit, skill, and agility in deceiving others” 6. The most important characteristic of the trickster is his ability to cross all kinds of boundaries, both in the spatial and temporal, as in the moral sense. Tricksters are disturbers of the peace as well as harbingers of salvation. They are parasites on the existing order. The trickster couldn’t care less about the rules of decency and taboos. He explores the margins in order to subvert the supposedly decent order of things. By doing so, he opens up places of wonder and creativity in an otherwise static world. The trickster transferred his character from the old mythical cultures onto various other creatures, one of which is the clown. The clown is therefore aptly described as a ‘border crosser’ 7. The clown is the fool, the ignoramus. His supreme wisdom lies in the fact that he knows nothing. But girded with this wisdom nobody can prevent him from speaking up. This way the clowns give a voice to the voiceless. Why, for instance, would they allow themselves to be intimidated by the great knowledge and scholarship of an ‘expertological regime’? Why should they shut up and not ask the ostensibly silliest questions? One fool can ask more than ten wise men can answer… The symbolic strength of the trickster, and thus of the clown, is enormous. It is no coincidence that their performance is intuitively and almost directly associated with life’s big questions and existential issues. This explains why since time immemorial clowns have been present in places and situations concerning matters of life and death. After all, that is where the boundaries and the framework of human life are at stake. B. Probing the Clown’s Boundaries Cultures differ in the way they draw lines in the sand. Clowns, being border-crossers, are therefore obliged to make different choices and find different means of expression depending on the culture in which they operate. The border crosser characteristic of the clown is on a more

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___________________________________________________________ fundamental level related to the uncertainty surrounding boundaries. Because what is a boundary? A sharp line or more of a grey area? Most boundaries, especially in a metaphorical sense, are not very clear and often of fleeting character. The art of the clown is a ‘transitory’ art par excellence and thus an art which unfolds over time and only exists as long as it is being performed. Through his play, the clown becomes the personification of the ‘uncertain boundaries’. His tear and his smile touch us immediately. We identify with him because of the directness with which he shows his emotions. The clown is vulnerable to such an extent that he disarms others. At every moment, the clown starts again, time and again. Once he is sad, he is profoundly sad. But a minute later that mood may have disappeared altogether. Improvisation is central to clowning, especially in the case of children with a disease. The performance turns into a unique occurrence, never to be repeated. The clown’s act exists as long as it is being performed. When it’s done, it’s gone. Clowning is a living art, dependent upon the animate presence of the performers, the audience included. That presence is disarming. Those hospital experts may do their utmost to show their ‘human’ face from behind their white coats, they remain representatives of the utilitarian, ‘expertological’ system. Relations between them and the children are from the very first moment under pressure from that functionality. The clown knows how to avoid this problem, precisely because of his identification with his role. The clear boundary between play and reality, between part and person, disappears in the clown’s performance. A clown can be trusted, and he can be trusted because he is disarming. Because the clown is a border crosser he is able to peek unashamedly into both sides of the border. A clown doesn’t take the slightest notice of the rules of the hospital. He shakes hands with the doctor and asks him whether he is the new cleaner. Sporting a deeply serious facial expression he’ll fool around with expensive medical equipment. A drip turns into a tube of tomato ketchup; a spittoon turns into a container of French fries. The clown is world-wise and a free traveller through all fields of life. This way he embodies all that the young patient has been denied. He is a spy for the little patients. Laughter is not the most important thing in the work of CliniClowns. The clowns don’t aim to score with their jokes and pranks. CliniClowns, through their work, aim to build a relationship with the sick children. That relationship is more important than the laugh as expressed in the basic principle of clown’s play: ‘position oneself under the child’. This expression, derived from the evocative language of the clowns, means that the child is in charge of the CliniClowns. The child is boss. Similar to a king and his jester, the child is in charge and the fool has to follow. This is not the same as slavishly doing what the child orders. The clown isn’t a supplier of entertainment and the child isn’t a consumer. The clown offers himself as a partner in a

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___________________________________________________________ relationship. Both he and the child enter an unknown adventure that develops spontaneously. The clown improvises and the child discovers it can influence that improvisation (which is different from guiding the improvisation). Spontaneous interplay results there and then. Together, the child and the clown create a situation which hasn’t existed in the hospital before, and won’t exist afterwards. Each of these situations is at odds with normality in the hospital system. 4.

The Sick Child Revisited

Essentially, the appearance of the clown in his communicative relation with the sick child concerns two issues: 1. Roles are reversed. The child is boss. Moreover, the clown plays a anarchistic role. He supports the child by mocking all ‘expertology’. By positioning himself “under the child” the asymmetrical and hierarchical relation between the child and the experts is disrupted, if only for a short while. 2. This role-reversal, however, confronts the child with itself and allows it to break free of this situation of relative isolation. The child is boss, but the clown executes his orders in his own way. The clown acts as it occurs to him. Comical situations are the result: a clown knocks over a glass of water. The child tells him to clean the floor. The clown takes a piece of cloth, cleans the floor, but proceeds in his idealistic zeal to clean the glass with the same cloth, only to refill it with water and to offer it to the child. This way, the clown puts the order of expectations into perspective. By doing so, he breaks through the pattern of expectation of the child, which it had acquired in the ‘expertological’ environment of the hospital. This way, boundaries are broken, which the sick child had experienced as galling bonds in the context of the system of care. Boundaries, which prevent him from being an out-and-out child and from developing into maturity through playfulness. Probing boundaries leads to opening them up. Freedom is the result. 5.

Why Hospital Clowning?

Now that we have elaborated on the situation of the child in hospital and on the character of the clown, it is useful to ask what hospital clown organizations should aim for. It is necessary to distinguish between the hospital clowns themselves (the profession) and the organization (which exists not primarily to serve the work of clowns but to achieve results for the child). Clowning is a means, not an end in itself.

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___________________________________________________________ As pointed out above, a child in hospital (or being cared for at home) runs the risk of losing itself; to lose touch with its own childhood. Ultimately, this could disturb its normal, natural development into maturity. The successes and achievements of paediatrics have ensured that many more seriously ill children will reach maturity despite the severity of their disease, leading as normal lives as possible after they have been cured. Apart from the implications of these successes in a medical and physical sense (infertility, certain physical defects), the psychological consequences have been even more underestimated. Therefore, it is equally important to provide children in these kinds of situations with the opportunity for play as it is to provide them with medical care. Obviously, hospital clowns can only partially fill this void but their contribution – as we have described above – is both essential and meaningful. Hospital clowns accompany the child in a moment of play, key elements of which are fantasy, surprise, inversion, and contact. These moments of play, therefore, are of much greater value and have a longer-lasting impact than the moment itself. 8. The ultimate goal of hospital clown organizations is thus not to provide joy, humour, and laughter to diseased children, but to make them get in touch with themselves and with the outside world (the world outside of the hospital). To break through the isolation which threatens the ill and the disabled child. By doing so, hospital clown organizations ultimately contribute to the quality of life of these children. This argument contains the risk that hospital clowning may be perceived as a therapy that can be applied methodically. Without a doubt: humour contributes to well-being; “laughter is the best medicine”, as the proverb goes. Empirical research can no doubt prove that humour has healing qualities. All of that is a welcome bonus but not of the essence. In a general sense, everyone within the world of hospital clowning is agreed on this, albeit for different and divergent reasons. The Danish clown Birgit Bang Mogensen relates her argument to the fact that humour is contextually dependent and thus to some extent untrustworthy as a therapeutic instrument 9. Yury Olshansky (Soccorso Clowns) considers the hospital clown primarily as complementary to the traditional work of medical doctors. “It is in no case to be considered as a therapy and it is necessary to be attentive not to create confusion on this subject”. 10 We would like to add another argument here. The moment the hospital clown is purposefully employed to achieve a therapeutic goal, defined in advance, all magic is lost. The trickster exists by the grace of his almost anarchic being. Becoming part of the system spells the end of the independence, the transparency, the ability to twist and turn, and to transform. Therefore, clown-therapy is even a logical impossibility because it is a contradictio in terminis.

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___________________________________________________________ “Inter-acting” without a specific target makes the difference between hospital clowning and medical care and cure. The child leads, not the system. Out of that perspective CliniClowns Netherlands has developed its strategy over the recent years. Here we will describe some of its elements, which might give food for thought or maybe even inspiration to others. Focusing on the child means listening to the needs of that child. These needs are different, depending on its situation, its illness, the duration of its illness and some other factors. CliniClowns, therefore, divided up its target group. Realizing that the real clown is a ‘scarce good’, CliniClowns was forced to develop criteria on which to decide in what kind of situations and cases real clowns would be provided. Speaking about imaginary boundaries, one might argue that where this boundary is ‘thicker’ or less permeable a more intensive contact between a child and a clown offers more added value to its well-being. This reasoning resulted in decisions about how often clowns and children meet, when to have private meetings or group meetings, and about the ‘platform’ used for a meeting. Until 2005, around 60 Dutch CliniClowns worked in more than 100 hospitals all over the country. We discovered that an important change was taking place within Dutch healthcare. At the start of the 1990s the average stay of a child in hospital numbered around 17 days. Ten years later this had fallen to less then 7 days. This meant that the care of a majority of the children moved from the hospital to the home. We realized that it would be impossible to reach all these children in the traditional way. Having two clowns visiting a thousand of them every week meant that we needed an extra 150 clowns! Not possible, but also not necessary. On the basis of the same principles as outlined above we decided to develop a high quality service for these children using the World Wide Web. A demand driven service, cliniclownesque in nature. One can understand that there was much doubt about the feasibility of high quality contact using the internet. Others worried about the identity of the clown. The result, developed by the Dutch CliniClowns, can be judged by the reader on http://www.cliniclowns.nl/ (click “diensten”, “villa neuzenroode.nl”, “stamp”. Unfortunately it’s currently only in Dutch). At this moment, six months after its launch, the fascinating world of clowns is visited by more than 200 children a week. They meet their clown via webcam, chat and e-mail. They also meet with other children. The children are just as enthusiastic as the clowns. The nature of contact is different, certainly, but of the same quality as meeting in the flesh.

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___________________________________________________________ 6.

A Charitable Organisation

The funding of hospital clown work differs from country to country. However, a factor shared by all is the recognition by the donors that clowning is charitable work. Private funds and corporate sponsoring are the main sources of income. Latent or manifest, in most (Western) countries hospital clowning has become more and more popular. In a way, this popularity may be considered as an expression of a keenly felt social need. Although there is yet not sufficient empirical evidence we dare to suggest that these needs originate from the same source as the profession of hospital clown. Healthcare in the western world is of a high standard. But, because of its technological and professional nature, it is to a large extent stripped of its human values, despite the enormous efforts to the contrary by the medical profession. It is a cold, result oriented system, in which the patient is object rather than individual. Respondents participating in recent research in the Netherlands mention a sense of injustice (“it is not normal that a child is sick and in hospital”) as one of the main reasons to support CliniClowns. This is a form of pure emotion. As the saying goes, the worst place to be ill is in the hospital. But since hospital care is sometimes inevitable we may as well ensure that the children receive the best treatment - in the broadest sense as possible. This leads to an almost unlimited trust in CliniClowns ensuring that the child within the child will not get lost in the context of the hospital. We contend that his is an expression of a latent need for a more humane and holistic system of health care, putting the patient at centre stage and not the medical technology. 7.

The Future of Hospital Clowning

This chapter was written some weeks before I retired from my job as managing director of CliniClowns Netherlands. Much has changed over the past seven years during which time I stood at the helm of the organization. At the moment the Dutch public considers CliniClowns the fourth most important charity, with only the Red Cross and some other well-known charities ranked higher. More than 150.000 individual people support CliniClowns financially on a regular basis. That is the case in the Netherlands. In many other countries of the world hospital clown groups are in existence or are starting up. They work professionally in hospitals and other health care institutions. They have become professionals and they are considered to be professionals.

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___________________________________________________________ It is time to realize this. For the sake of sick children wherever in the world, it is necessary to further develop this profession together; to intensify scientific research into the impact of hospital clowning on children; to exchange and further develop hospital clown methodologies; to exchange and improve knowledge about societal support, in whatever form; to rethink the inhumane nature of our healthcare system. It is time to deepen our shared knowledge. It is time to ensure on an international level the professional standards, which are being developed nationally. It is time to come together and to start exchanging knowledge, experiences, and methods. Hospital clowning has become serious business over the past 20 years. This has happened because of a deeply felt fundamental need for humanity in the technological context of a hospital; it has happened because a child has the fundamental right to play and develop, even when sick or disabled.

Notes 1

Joachim Meincke (ed.), Clownsprechstunde-Lachen ist Leben, Bern, 2000. 2 These two paragraphs rely mainly on the unpublished notes by Dr. Christian Doude van Troostwijk for Foundation CliniClowns Netherlands (2001). 3 Harry Kunneman, Humanisme, postmodernisme en het deskundologische regime. (Utrecht: Universiteit voor Humanistiek, 1989), pp 35-36. The proposition on the ‘expertological regime’ is elaborated upon in Harry Kunneman Van theemutscultuur naar walkman-ego. Amsterdam: Boom, 1996. 4 The assumption is that the system of the family changes dramatically the moment a child has to be nursed at home for an extended period of time. The situation at home will start to show the characteristics that apply to the system of a institution of care. After all, the situation at home has been incorporated in the system of care as such. 5 Constatin von Barloewen, Clown. Zur Phänomenologie des Stolperns. Königstein: Athenäum, 1981 6 Borgman, Erik in : Sexson, Lynda, Gewoon heilig. De sacraliteit van het alledaagse leven. Zoetermeer: Meinema, 1997, 158. 7 The word clown is derived from ‘colonus’, the 16th Century slang Latin word for ‘peasant’. This emphasised the crude and archaic essence of the character. 8 See: Caroline Simmonds & Bernie Warren, The Clown Doctor Chronicles. Amsterdam: Rodopi, 2004. 9 Nina Gladkowa og Birgit Bang Mogensen, Klovnen og humoren- som kommunikationsmetode, Skejby, 2003, p.33.

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Arts in hospital and healthcare – report of the First European Forum, Paris, 2002, p.105.

Author Tom Doude van Troostwijk was the managing director of the CliniClowns Netherlands Foundation from 1999 to 2006.

Clown Language, Performance and Children’s Hospitals Ana Achcar Abstract This report is part of ongoing research which aims at developing a methodology for educating and training actors in “clown language”, prior to performances in children’s hospital environments. The basis of this research involves an investigation of the relationship between laughter and health; clown and child; reality and fun; and art and transformation. It is intended to serve as a deeper exploration into the interdisciplinary assumptions behind clown performances in hospitals, as well as the basis for a professional training program for actors in this type of activity. 1.

Introduction

Since 1998, I have been managing the Enfermaria do Riso * an interdisciplinary education, action and research program, which was set up at the Drama Department of the Drama School in the Federal University of Rio de Janeiro’s Language and Arts Centre. The Program organises the performances of drama students in the paediatric areas of Gaffrée & Guinle University Hospital - HUGG (outpatients’ clinic, paediatric ward and ICU), with the objective of bringing humour into the hospital environment and the relationships established within this setting, reinforcing the human quality during these encounters. With such programs, we hope to help change the emotional conditions of hospitalized children, providing relief from the stress generated by certain medical procedures, and promoting more positive attitudes from the child in the face of their illness. Throughout the years, I have seen that the hospital environment contains elements that correspond to the principles upon which clown training for actors is based. As a result, I have developed a structure for practical exercises that have been tested with drama and medical students and which, when organized, could contribute to the elucidation and understanding of the direct connection between arts, humour, treatment and healing. My proposal is to share this experience, presenting evidence that supports our work in the hospital. 2.

History

The Program, which covers the fields of Drama and Health, is managed by myself with the collaboration of Professor Édson Liberal

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___________________________________________________________ from the Paediatric Department of UniRio´s Biological Sciences and Health Centre, as well as contributions from students and teachers of both areas. The Program uses, as its activity areas, the paediatric rooms of Gaffrée & Guinle University Hospital -HUGG and classrooms of the Language and Arts Centre. The Program provides education and training opportunities for Drama students by means of elective subjects offered in the Dramatic Arts course, and in extension courses given by professional artists. These extension courses provide training in magic, puppet making and handling, music perception, and improvisation. In addition, the program arranges for meetings with psychologists that who deal with child development, and set up workshops for the clowns to exchange their knowledge. In the last three years, apart from the theoretical and practical course on the dramatic aspects of the clown’s game, the students were able to study subjects such as magic, the creation and manipulation of puppets, musical perception, and body movement improvisation; they were also able to attend workshops and meetings with psychologists dealing with child development; and workshops with actors that have performed as clowns to exchange techniques and experiences. At the Hospital, the students have been working in pairs, regularly, from March to December, twice a week, during the mornings. As nurse-clowns 1 they perform parodies of medical procedures and nursing routines, using games and theatrical improvisations based on the imaginary universe of children. They use medical examination instruments, such as the stethoscope or the syringe, attributing unexpected and original functions to them; suggesting a new way of seeing the reality that surrounds them. Each shift, they visit the outpatients’ clinic and its waiting room, the haematology centre, the ICU and the Paediatric ward of the HUGG, exploring the physical space, specific sounds and characteristic objects. They work to establish new and ludic relations with those who use such spaces, be they doctors, nurses, patients, relatives or members of staff. In the realm of institutional and postgraduate research in Drama, the Program Enfermaria do Riso inspires investigations within the University that concern the development of clown dramatization, systemization of a methodology for training of students that work at the hospital, and the gathering and inquiring of drama principles that take place in non-theatrical environments, all of which are in process. 3.

Space and Imagination

The paediatric facilities of the Gaffrée & Guinle University Hospital are divided in four areas. The first working area is the outpatients’ clinic, located on the second floor of an exterior construction

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___________________________________________________________ of the hospital building. It is made up of five small compartments; in each, two doctors attend two patients at the same time. There is a large space on the outdoor terrace where the children and their relatives wait for their turn to be seen by a doctor. Normally, it is a very agitated environment. The two floors are connected by a large concrete staircase, which is visible to those waiting and to those at the entrance of the reception. The second working area is situated at the haematology centre, in a room reserved for children that come, generally, to receive intravenous AIDS medication. There are two or three chairs and a stretcher occupied by children that can’t move around nor make any large movements. The access to this room, which is located at the end of a great hall where there is always intense transit and a great number of people waiting to be attended by different sections of the hospital, is not controlled. The third area is the paediatric ICU, situated at the end of this same hall in a room that does not have any partitions and where five incubators, a small isolation glass room, a nursing station and a large office desk are spread. The access is restricted. At last, and situated above the ICU, is the Paediatrics ward, made of two large rooms, each with an average of eight beds for children and the relatives that stay with them. There is also a nursing station and three rooms; a dressing room for the nurses, an office for the chief nurse and the doctors’ meeting room. 2 According to the definitions of space given by Marc Augé , the hospital can be considered a non-place. The hospital space is one which no one wants to belong to, a space where one hopes to leave soon. For the doctor or nurse, or any health professional, the space does not contain that which has to be confronted. These characteristics are confirmed by the clown’s work, which by revealing the space as a fundamental element in the construction of his performance, introduces a surprising relevance to something no one wants to pay attention to. The hospital, such as we know it today, is a relatively new space, which dating back only to the end of the 18th Century. According to M. 3 Foucault , medicine was not a hospital practice before then. The hospital was a place for the isolation of the bearers of contagious diseases. It was a place where the ill went to die – and in this sense, it relates to the definition of organized space by emic strategy, given by Zygmunt 4 Bauman, “...‘to vomit’, to spit at others who are viewed as hopeless strangers: to prevent physical contact, dialogue, social interaction and every variety of comercium, commensal e connubium. The extreme variables of this ‘emic’ strategy are today, as

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___________________________________________________________ always, the imprisonment, the banishment and the assassination. The high forms, ‘refined’ (modernized) of the emic strategy are the spacial divisions, the urban ghettos, the selective access to spaces and the selective impediment of its use” It is interesting how the hospital, nowadays defined as a place for recovery, where the ill goes to live, still has in its spatial organization the same emic sense, with its inaccessible wings (ICU, ER, Surgical Centre), small partitioned environments specifically separated from one another (the compartments from the outpatients’ clinic and from the haematology centre), and its obstructions of use, even if temporary (the ward visiting hours). The clown works his body in this fragmented and limited spatial structure and through his actions, that is the relation of his movements in space and time, he brings together areas that were isolated by walls, doors and wardens. He attributes, therefore, new meanings to the very organization of the place. The hospital’s organization of space is inherently connected to the practice of medicine. The birth of clinical medicine is the turning point from how, previously, the treatment of an illness was focused on the ill, by means of relating symptom, lifestyle and the patient’s habits, in order to name diseases according to a botanical classifying system; to how, in modern days, the practice focuses on the body as an object of scientific research where one can reach the centre of the disease, while still retaining knowledge of the individual behind the body. After five years of experience, we have come to the conclusion that a great part of the success of the clown’s performance in the hospital environment, and among those who are part of it, is due to the possibility of fully attributing function and meaning to the space. The study of these transformations has been the basis of our attempt to systematize the activities of the clown at the hospital environment. In our training courses, the relationship that the clown establishes with the space usually develops from exercises that work with at least three spatial orders, as I define them. This means that the movement of the body in space always reveals a level, it is executed in a place and has a direction. The purpose here is to allow the actor to succeed in seeing the acting space in a different way from the one he is used to on a daily basis. The new viewpoint that the clown brings to the hospital space is astonishing and plays a fundamental part in the transformation of the environment. The clown attracts attention to that which is still healthy in the sick individual. An ill child an almost perfect capacity to play a different reality, even though it may often be hidden. By playing, their strength is

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___________________________________________________________ restored and that is all they need to fight the disease. Even if they can’t objectively do anything, at a subjective level they do not feel as impotent 5 once they are doing what they know best . Therefore, the quality of the relationship with space offers the clown a main ally for establishing a game with patients and parents, as well as with doctors, nurses, and members of staff. The improvised situations brought up by the clowns at the hospital transports the game to other places, by attributing new meanings to the known and daily spaces. Such new meaning is not homogeneous, even though we are experimenting with some rules that could organize it at the training course.

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Time and Quality of Action

When the performance of a clown contributes to the transformation of an environment, it is acting simultaneously over the reality of that space, and, essentially, over a construction of time, which means the association of a duration, a sequence, and a rhythm. The body of the clown in action explores two characteristics of time: one is objective, quantitative, external and refers to itself; and the other is subjective and qualitative, which is necessary in order to be rebuilt by a 6 symbolic system . In fact, we have been dealing with an important issue since the beginning of our work at the hospital, concerning the time lengths of the interventions. Given that we are working with improvisations, there is not a predetermined end, and even though there are performance scripts, it is the clown, and his in loco perception, that decides when the game ends. Practice has shown us, however, that the determination of the time length is also subject to at least three other temporalities that concern the paediatric patient: the length of stay at the environment (given by the place where the child is); the life time of the child (taking into account that the sick child has actually two ages, one chronological and another emotional); and, the duration of the disease (which many times does not coincide with the length of time the child has been at the hospital nor with the graveness of the disease). On the paediatric ward, when children have been hospitalized for a long time, they expect the clowns as they know that they come twice a week, and there is an expectation towards a continuation of the game started in the last intervention. This does not happen at the outpatients’ clinic, which children attend for shorter and more sporadic periods of time. These children are stronger, more physically resistant, and have more energy than the ones who’ve been hospitalized for a longer period, and so it is necessary to be careful not to extend the game too much, because over-stimulation might bring them to burn down the hospital after the clowns have left. In both cases, it is also important to notice the age of the child. The older ones, in the way they react to the games, may even decide the moment when it should end. For babies, sometimes, the duration of a single song is enough for them to calm down or even for their mothers to calm down. With the exception of the waiting area of the outpatients’ clinic, where there is an average of 15 to 20 children waiting at the same time, the clowns usually concentrate at one child at a time. The child organizes his perceptions according to an impression of time. It is the perception of time for this relationship to begin, to develop and to end. In fact, it is not about ending something, but transforming the quality of the game. Usually difficulty in determining the duration of a game with each child is

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___________________________________________________________ connected to the difficulty of leaving without abandoning the other. This means that when that specific and concrete game between the clown and the child is over, another game still goes on, on a more subjective level, inside themselves. Taking into account the work done at the university hospital, we have observed that the quality of the clown’s performance is completely related to the way it is structured in time. This differs from the content of the performance, which seems to be more related to the work concerning spatial orders (place, level, direction of movement). Organized through time by the choice of an external rhythm, but also sustained by an interior beat determined by his breathing, the clown’s performance has the possibility of being worked in its nuances of expression. Through his connection with time, the clown details his performance, and attracts attention to his humanity and individuality. He is unique and there in no one like him. This is a very important perspective because when he establishes a relationship with the other, be it a doctor or patient, adult or child, the clown introduces a personal and irreplaceable moment, thus artistically justifying his performance. 5.

The Selection of Students

Each year I receive a new group of fifty young students who wish to participate at the Program in the University. I must make a selection (each year I can admit only ten new students) and, at this moment, important issues that will accompany us throughout the selection process are taken into consideration: Are there personality traits appropriate for this work? Is there an ideal age for doing this? How much time do I need to prepare these students to act as a clown in a hospital? Can this action be learned? In fact, these questions should not be answered in this initial part of the selection. They would be more appropriate at a second selection that happens naturally during training and the internship at the hospital. Anyway, these young students have a great desire to discover the hospital as a space for acting, not only for the possibility of exploring a new niche for their acting career, but also because of personal and artistic gain that the interdisciplinary activity brings to the exercise of their art. At least, these are the main reasons given by those trying to be admitted at the Program, shown in the letters of intent and in the interviews that complement the practical examination that they are submitted to. The criteria used nowadays in the selection of students have been gradually established from the findings of the needs and demands of the work at the hospital. Some of them are objective and general, being supported by the fact that the performance of the clowns in such environments follows certain rules of theatrical game and of dramatic

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___________________________________________________________ construction, and it is conducted by psychological principles that sustain and support the relationship and the gathering of human beings. Other criteria are of a more subjective and personal order, like those guided by a particular instinct that generates the choices that artists have to deal with when they are going through a creative process. Therefore, far from being firm, rigid and affirmative principles that distinguish an error from a determined truth, the selection criteria that we use are interrogations that help us with the appreciation and the perception of certain elements that come forward when the candidate is doing an exercise or is being interviewed. Kevin Kuhle, professor of the New York University, proposes some of these questions when he describes a selection process 7 for the admittance of Drama students at the University : ...does he seems to be guided by a creative artistic need? Is he transparent? Does he easily get in touch with his emotions? Does he know how to deal in a dynamic way with the offered material? Does he give the impression of doing something and not just transmitting an information? Does he have an adventurous spirit? What has he accomplished in his short life? Does he have ideas about art and theatre? Is he well prepared? Does he listen to what he proposes? What does he have on his body? Since, in our case, the student is applying for a training course for clown performance in the paediatric field of hospitals, there are some specific elements that constitute this activity which we expect to observe in his/her behaviour during the selection process, such as the ability to say yes, even when the situation turns difficult and the problem seems to have no solution, showing openness and availability to try as many times as necessary; respect the intimacy (vital space) of others; enjoy being in a relationship with other people, above all, seek those relationships at all times. Actually, we are looking for signs as to how they relate their exterior reality (the other, the word, the object, space, time) with their inner self (memory, expectation and desire, imagination, senses, impulse and breathing). What is more important than obtaining success or not during the experience is the attitude and positioning during the exercises, if they can be available yet show resistance, if they can have strength yet demonstrate sensibility. 6.

The Clown’s Training

In the classroom, we do not develop the training with the idea that the clown is a character, but we develop a process for finding innate

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___________________________________________________________ characteristics in the actor that, little by little, reveals “his own” clown, thus assuming a personality during particular actions with his own logic and incorporated in a specific body. Hence, one of the basic principles of the training we propose is based on the research of this innate comical state, intensity and rhythm. In fact, qualitatively, the work on rhythm plays a fundamental role. Rhythm is a form of body perception of time that, according to 8 Norbert Elias , is a social and cultural and also physical construction. Both in life and on stage, everything that lives has a beat and the possibility of rhythm. In the clown’s case, the rhythm is, at the same time, the motive and the form of expression of his performance. Given the assumption that the clown is not a constructed character, but an innate characteristic that the actor finds out in himself, the clown becomes his own rhythm. According to the definition given by the Brazilian musicologist Bruno 9 Kiefer , the word rhythm – in greek rythmos – designates that which flows, which moves, associated with the idea of measure and order. For the author, if nothing is altered, there will be no notion of rhythm. It will only appear with the discontinuity of the flow, that gives a perception of comparing and measuring fragments of that which flows. If such discontinuities occur chaotically, they will provoke a feeling of confusion. Hence, when we speak of rhythm, it means that there will always be an order involving the steadiness of elements, that are, if not the same, at least comparable. When we tell a student that it is necessary to work out the clown with rhythm, we are reminding him to work with that which “flows and moves” with the purpose of trying to find a measure and an order for him. To find “your” clown is to work with your inner self and your subjectivity, with the intention of finding a logic and an exterior and physical form that expresses them. So, a way of moving in a given space may become a demonstration of a way of thinking. When a clown is created by an actor, the individual in his singularity comes into evidence and he is forced to develop a close correspondence between inner self and form. The clown is born in misunderstanding, in exposure of frailty and limits of the human condition, in a process of creation that is developed in the tough, yet beautiful exercise of self knowledge, as well as perception of the other, hence discovering and exploring space as if for the first time. The clown is the creator of his own material, which means that everything is built by himself. His abilities and weaknesses are unique and individual. Another principle that guides our training is the development of the clown, not quite as a person who makes us laugh, but as one who exposes the limits of his human character. During the learning process of the mechanisms of a clown’s performance at the hospital, humour and laughter are experimented with through the unexpected actions and

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___________________________________________________________ attitudes of the games and exercises, through revealing individual circumstances, through personal disclosure of each story and of each way of being and through the ability of each one to assume his ridicule, his errors and his humanity. Therefore, the training attends to the needs relating to the work in the hospital; communication with the other, as well as meeting the other’s needs. Hence, the training exercises are thought to be instruments of disclosure for a unique comical characteristic, which gives the each individual opportunities to place himself at the space of laughter. Luís 10 Otávio Burnier states that what we consider to be funny in a clown is due to his expression of discomfort and insecurity before the public. The clown only becomes aware of his stupidity after being stupid, and since he cannot fix his mistake, he cries. The public laughs and the clown cries. That is why we work with humour from the opposite poles between doing it right and getting it wrong; the will of doing something and the impediment; logic and chance; memory and present. What the clown sees, the others do not see, and he sees his own way of thinking the reality. The clown that stands out as an innate ability, a rhythm, a mask, will work with reality, at all times, as if he had discovered it for the first time. We believe in this experience of the surprise element as a way to work with a determined time and space, so the comic action can be constructed. Technically we also practice traditional exercises of repetition, imitation and exaggeration of actions with the intention of finding the comic in the clown. 11 According to André Riot-Sarcey , the creation of a clown originates with the gathering of memories from childhood objects and photographs, the recollection of original emotions that had been forgotten, the finding of other forms of laughing and crying. This is a state of deep personal maturing of each one of the participants involved. In fact, our interest in the comic will occur whenever it reveals and reinforces the human condition of the clown. It is precisely the humanization of the relationships that we are looking to achieve, when we propose the performance of clowns in hospital environments. We do not dismiss the importance of the laughter of those that come into contact with the clowns at the hospital, but we hope to establish a relationship with the other and, through it, create the possibility of transforming reality. On certain occasions, it is sufficient for us that the hospitalized child simply looks away from the television, for example, and looks at the clown. In our evaluation, this attention may have the same strength as a smile. At other times, even if the child says no to the clown and refuses to play with him, such repellence, in an environment where they do not normally have the right to refuse, can be considered as an reaction as beneficial to the child as a good laugh. It is important to make sure that the

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___________________________________________________________ relationship is established individually, so that each reaction can be interpreted and developed taking into consideration the characteristics of each case. The characteristics include: the child’s age, the motive and time of his hospitalization, the treatment he is being subjected to, who is accompanying him, and his social and economic status, just to name a few. 7.

Interdisciplinary Action

During its five years of existence, the Program Enfermaria do Riso has been gathering data and accounts experiences arising from this new place of practice and artistic contemplation; that is, the performance of clowns in the environment of hospitals devoted to the treatment of children. Quantitatively, we have worked with an average of eight hundred people a month at HUGG, including paediatric patients, parents and health professionals. Regarding its qualitative impact, it is important to underline the matter of the interdisciplinary connection between Drama and Health and how it came to be. At the time it was being considered, the creation of the Program had the fundamental support of the Extension Department. The connection between the Drama School, the Medical School and the Paediatric Department was carefully planned and guided by the Extension Department, which was concerned with the construction of a more effective and consistent exchange between apparently separated courses. Exploring the unknown territory of research of new languages and spaces becomes even more pleasant and efficient with the support of solid institutions that have more daring visions for programs of social extension and higher education. Up until now, what we have been able to assert is that the interdisciplinary experience has offered our students the possibility of contemplating and discussing matters concerning the function of the actor outside his usual place, where the limits of artistic experience are found within social practice. Participating in the activities of the Program Enfermaria do Riso liberates them from an exclusively egocentric approach, set in obsolete concepts about the function of the actors, and develops the perspective of artists as creators of new spaces of expression. There is a great interest in this perspective. When we started the Program in 1999 at the Drama School, twenty-five percent of the students applied for a place. In fact, the work developed by the clown at the hospital attracts attention by his necessity of being in relation, co-operation and collaboration with the other (whomever the clown works with; patient, visitor or staff). The clown does not exist without the other. Actually, he lives for the other and because of the other. His art consists of relationship

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___________________________________________________________ and involvement with the other. And it is from this close relationship that the ludic element of his performance is born and, thus, establishes itself as a game. A game of self revelation that puts the other into evidence and makes him discover himself. We find it amusing to recognize our weaknesses in the clown and we surprise ourselves when we discover in this attitude the recognition of our strengths. The clown invites us to experience reality through the senses. He teaches us to laugh at ourselves. The clown accepts his own ridicule and exposes himself. Even if he is clumsy or a loser, the clown never gives up trying one last time, and the relationship that is established between failure and achievement demystifies the assumption of being better than the patient. This ludic quality present in the clown’s world is far from being found in the environment of a hospital, but his universe is very close to the child’s and this proximity rapidly generates complicity between them. The approach, on another level, with the doctors and nurses and even with the parents, in some cases occurs through the child. The clown, when integrated to the hospital environment, uses elements in a ludic way, such as the white medical clothes, syringes and stethoscopes – references of the medical world – depriving them of the meaning that distinguishes the hospital as an institution through the use of humour and, at the same time, reinforces the medical actions by looking into what is still healthy in a sick child. Therefore, the actions of both teams allow, at different levels, a more efficient and less traumatic process of recovery by looking into the singularities of each patient. Our training is also offered to medical students, residents, doctors and nurses through a drama workshop called O Riso na Saúde (Laughter in Health), that takes place at the facilities of the University’s Hospital. Every time we do this event, we uphold the belief that it is necessary to maintain and strengthen the co-operation between the professionals of the fields of Health and Drama in regards to the development of the Program Enfermaria do Riso at the University. Even though it was an initiative of the Drama School, the continuation and consistency of the clown’s work at the hospital is closely related to the participation of the Medical School and of the professionals who work at the HUGG. The artistic quality of the performance of the clowns depends on the co-operation of the doctors, nurses or residents, who provide, for example, information on the child’s health, humour, relatives, and medications; thus supplying the clown with elements that will facilitate the relationship between the artist and the patient. But more than just being responsible for reporting the child’s conditions, the medical team is an important ally to the performers in differentiating the presence of the clowns from the painful procedures that the child has gone through or will be submitted to.

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___________________________________________________________ The evaluation of the actions of our Program is another matter that comes up when discussing the interdisciplinary quality of our activity. Monthly reports have been completed by the Drama students and meetings with the medical team of the Paediatric wing of the HUGG have occurred, as an attempt to evaluate the Program. During such meetings, we also have the opportunity to present the Program Enfermaria do Riso to the new residents and medical students that arrive at the hospital each year. What we have realized is that as an interdisciplinary action there is a need for variation and adaptation of interpreting methods of the obtained results. We have, therefore, elaborated instruments of qualitative evaluation that involve every part of the Program: from meetings about the experience of the interventions at HUGG with the participation of professionals from the Paediatric Department and of students/actors that participate in the Program Enfermaria do Riso, to interviews with the hospitalized children and their relatives, both before and after the performances. With the children, we use methods of evaluation that are illustrative (drawings, figures done with Play-doh, etc). With the adults, written questionnaires are used, as tape-recorded interviews, if circumstances warranted it and permission was given. Anyhow, each relationship that is established between the clown and the doctor, nurse, child or relative is a four hand written story. From a certain point, it becomes impossible to fully know who is in command of the artistic game that is created, given the great mutual dependence that is formed by both parts. In this sense, the Program Enfermaria do Riso shows us that the interdisciplinary nature of its fundamental action is beyond the initiative of sharing spaces, researches, teachers and students of both Departments. The intersection between the performance of the clown and the action of the health professional is created out of the needs of the child, and together the three of them find out, when meeting one another, the freedom and irreverence of this place of laughter, where there are attitude changes and changes in human relations. The question of humanizing the Health area is at the centre of debate in Brazil. The transformation of the hospital environment and the resulting change in the quality of relationships, as well as a more positive attitude of the diseased child and their relatives towards the illness, a better resistance to the long term hospitalization and to the painful and invasive exams, and the humanization of the relation between doctor and patient are possible consequences of the work done by the clown in a hospital environment. On the other hand, the practice of humanity that drama proposes is unquestionable. Drama is the art of self relating. Drama must accomplish the duty of approaching men and making them see their differences and similarities. When an actor chooses the clown to work in a hospital, he is choosing his artistic language as an instrument to relate to the other. On an academic level, when the student goes through this

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___________________________________________________________ experience of being in deep relationship with the needs of another, regardless of his condition, he is increasing the technical and/or artistic range of the offered subjects, allowing for an important humanitarian learning to take place in his professional education.

Notes *

Laughter Ward or Laughing on the Ward As opposed to the clown-doctors of Fools for Health, the Humour Foundation and other organizations, our clowns take on the role of nurses. 2 In Augé, Marc. Não Lugares – Introdução a uma antropologia da supermodernidade. Campinas,SP: Papirus, 1994. 3 In A Microfisica do Poder– Cap. O Nascimento do Hospital 4 In Zygmunt Bauman, Modernidade Líquida. (Rio de Janeiro: Jorge Zahar Ed., 2001), p. 118 (translator’s version). 5 For the adults that surrounds them, parents and relatives, doctors and nurses, the process happens in a similar way, the difference lies on the fact that with them it is necessary to invoke what is left of their childhood, and many times that is not so evident anymore. 6 Definition of the natures of temporalities given by Patrice Pavis in “Dicionário de Teatro.” Pavis, Patrice. Dictionnaire du Théâtre. Paris:Editions Sociales, 1980. 7 In Josette Feral, L’École du Jeu org., (Saint-Jean-de-Vedas:L’Entretemps Éditions, 2003) 99 (translator’s version). 8 In Norbert Elias, Sobre o tempo. Rio de Janeiro: Jorge Zahar, 1984. 9 Bruno Kiefer, Elementos da Linguagem Musical. (Porto Alegre: Movimento, 1987), 23. 10 In Luis Otavio Burnier, A Arte de Ator – da Técnica à Representação (Campinas, SP: Editora da Unicamp, 2001), 218. 11 In Clown- o termo - Clownews – Boletim Informativo dos Doutores da Alegria. São Paulo: Abaeté, 1999. 1

Author This study is part of the doctoral research of Ana Achcar who teachs acting at Theatre School in the University of Rio de Janeiro (UNIRIO) where she has been managing the Enfermaria do Riso Interdisciplinary Education, Action and Research Programme since 1999.

LaughterBoss – The Court Jester in Aged Care Dr. Peter Spitzer Abstract Care of the growing elderly population in Australia is under increasing pressure. Staff stress is chronic and morale can be less than optimal. There is evidence of the value in consciously introducing laughter into aged care facilities. The LaughterBoss is a new model where a staff member is trained to bring humour into their facility. Their role and training is discussed. The LaughterBoss can be seen as the reincarnation of the court jester in the new millennium. They utilise performance skills to manifest the art of medicine at this difficult late life stage to make a positive psychosocial impact. “It’s the job of the LaughterBoss, via open-heart surgery, to touch the soul and open the door to smiles, play and laughter.” 1.

Clowning in the Health Care Setting

On the front page of the September 1908 issue of Le Petit Journal there is a drawing of two clowns working their craft in a London children’s hospital ward. In Turkey, several centuries ago, the Dervishes who were responsible for the well being of patients, first, fed the body and then used their performance skills to feed the soul. More recently, hospital clowning has become established in many countries with palpable benefits to patients, families and staff. Patch Adams, as a young doctor in the 70’s, began clowning for hospital patients. Big Apple Circus established the Clown Care Unit in New York City in 1987 and was the first structured hospital clown programme with frequent and regular visits to host hospitals. There are many hospital clowning programmes around the world and some of there are Theodora Foundation (Europe, South Africa, Hong Kong and Belorussia), Le Rire Medicine (France), Die Clown Doktoren (Germany), Payasospital (Spain), Soccorso Clown (Italy), CliniClowns (Europe), Doctors of Joy (Brazil), Fools for Health (Canada) and Humour Foundation (Australia). Today, hospital clowns work in partnership with other health care providers. Clowning in hospital addresses the psychosocial needs of patients as well and the facility as a whole.

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Clowning and Evidence-Based Medicine

Gelotology is the study of humour and its effect on the human body.1-5 The Association for Applied and Therapeutic Humor (AATH), founded in 1988, defines therapeutic humour as “any intervention that promotes health and wellness by stimulating a playful discovery, expression, or appreciation of the absurdity or incongruity of life's situations.”6 Clowning has a long history of being an art form that invites play, interaction and above all laughter. Many studies on the effect and benefit of humour and laughter have been published and a small crosssection of papers is referenced here. Laughter affects the mind and the body. There are many reasons why laughter makes us feel good and a recent study has found that humour and laughter triggered the brain’s reward centres.7 Other studies show respiratory and cardiovascular effects. Laughter stimulates respiration, relaxes arteries and improves blood flow as well as oxygen saturation of peripheral blood. After a transient rise there is a drop in blood pressure. Positive effects on hypertension and diabetes have been noted. A relaxation response is experienced after laughter. Laughter has been researched in the field of psychoneuroimmunology and studies have shown a drop in serum (cortisol) stress hormone and enhancement of immune system functioning. Laughter reduces pain. Laughter is also studied in the field of Positive Psychology and positive effects on performance, mood, optimism, anxiety and depression have been observed. Laughter enhances communication and is positively associated with emotional stability. Finally, there are many published studies on humour and laughter in aged care and a short list is referenced.8-17 3.

The Humour Foundation18

This is an Australian charity dedicated to promoting the health benefits of humour to patients, their families and health care professionals. Founded in 1997 by the author, a medical practitioner and Jean-Paul Bell, a professional performer, the Foundation’s core project is the Clown DoctorTM Program.19 Clown Doctors are professional performers trained to work in the sensitive hospital setting and touch the lives of over 75,000 people a year. There 50 Clown Doctors based throughout Australia’s capital cities visiting paediatric and general hospitals, palliative care facilities, regional hospitals and nursing homes. With The Smile Around The World Project, Clown Doctors have helped people find their smiles again in East Timor and Afghanistan.

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___________________________________________________________ The LaughterWorks project provides speakers and workshop presenters on humour and health topics. LaughterBoss training is a LaughterWorks project. 4.

Aged Care Issues and Depression

Not that long ago, life expectancy was in the 40-50 range. Now, it is common to be caring for people who are in their 80’s and 90’s. This group suffers loss of physical and mental ability, loss of power, loss of friends, loss of control in their lives and loss of independence. Depression is common at this late stage of life and brings with it significant morbidity, which when left untreated is associated with higher health service utilisation.20 Depression is a major public health problem. It is common for depressed older adults in residential care not to receive optimal help as depression is often under recognised by health professionals and other carers. A crucial issue in health promotion intervention is to increase participation in both mental and physical activity. Common health education messages include; depression is not an inevitable part of ageing, depression is not a spiritual or personal weakness and non-pharmacological treatments can be effective when used alone.21 Multifaceted interventions have been recommend due to complexity of depression in residential care as well as the potential for synergy between different elements of possible interventions.22 However, cost of funding is a common factor in introducing intervention programs. With an increase in the aging population, the aged care health sector in Australia is under growing pressure. Staff stress, morale, burn out, turnover and absenteeism are recurring problems. In summary, implementing effective depression interventions can positively affect quality of life and reduce physical and psychological morbidity and consequent patient transfers to higher levels of supportive care.23 5.

The LaughterBoss Concept

Whilst we saw and felt the impact of Clown Doctor visits at aged care facilities, we were not able to make regular visits, which limited the impact and connection with everyone in the facility. The commonest complaint was, “Why don’t you come more often.” This signalled an inadequately met need. With the increasing demand for Clown Doctors to visit aged care facilities, the author developed the LaughterBoss concept and presented this model at The First National Conference on Depression in Aged Care: “Challenging Depression In Aged Care” at the University of NSW, Sydney, Australia, June 2003.24

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Who and What is the LaughterBoss?

The court jester (or fool) was a particular type of clown associated with the Middle Ages. In those days they were thought of as special cases that God had touched with a childlike madness. They wore bright, motley patterned, costumes and floppy cloth hats with 3 points each having a jingle bell at the end. They also carried a mock sceptre. Medieval medicine considered health to be largely governed by four humours (Sanguine, Melancholia, Choleric and Phlegmatic). Imbalance of the humours produced distinctive emotional states and the court jester was specifically employed by the court to help rebalance the humours. For example, the court jester would be summoned to lift the monarch out of an angry or melancholic mood. “Above all he uses humour, whether in the form of wit, puns, riddles, doggerel verse, songs, capering antics or nonsensical babble, and jesters were usually also musical or poetic or acrobatic, and sometimes all three.”25 The tradition of court jesters lasted about 400 years and they worked in the royal courts of Europe, the Middle East and Asia. The LaughterBoss is a modern day equivalent of the court jester. The main role of the LaughterBoss is to bring play, humour and laughter into the facility. This role originates from the philosophy that laughter is the best medicine. The healing power of humour is well documented.26,27,28 Sharing a smile and a laugh, reduces anxiety, positively impacts on the immune system, improves circulation, modulates the mesolimbic reward centre29, reduces depression and creates an atmosphere of positivity and warmth. While the main focus of the LaughterBoss is on the residents, a positive impact on staff, visitors and the general community has been reported. The LaughterBoss can reduce staff stress and improve morale as well as assist staff to better meet quality of life and psychosocial needs of residents. This is done through assisting communication, increased support, giving residents cognitive control, providing positive diversion and generally increasing the ‘smileage’ factor. Ideal candidates for LaughterBoss training are facility staff members who have an intimate knowledge of the people (residents, staff and families) and a thorough understanding of the environment and culture of the facility. The LaughterBoss role has been added onto the ‘day job’ of chief executives, directors of nursing, charge nurses, enrolled nurses, nurse’s aids, diversional therapists, occupational therapists, physiotherapists and clergy. Having a staff member as the LaughterBoss addresses the funding issues and enhances recommended multifaceted interventions. Usually candidates self-select to attend training but they must have the approval and enthusiastic support of their management.

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___________________________________________________________ After training, the LaughterBoss is a new identity in the facility. They should be easily recognisable and be available to do their work at a moment’s notice as the need arises. They also lead the way in introducing themes, special days and events. 7.

LaughterBoss Training

Training does not make the applicant a professional performer. They remain a healthcare professional who has developed creative skills in introducing humour and laughter into their facility. Initial training is an experiential full day, limited to 20 to 30 people. Hospital clowning and LaughterBoss models are introduced and reviewed and issues about introducing these models into the health care setting are explored. Training includes; evidence-based medicine, psychoneuroimmunology, positive psychology, engaging the older resident, developing a new and different view of residents, staff, families and the environment, brainstorming humour, introducing play and the role of the ‘play basket’, using props as communication tools, dealing with resistance and improving self-care. Other strategies such as musical opportunities and introducing a mobile humour cart are also explored. Experiential play activities are introduced throughout the day. Trainees receive resource materials and networking with people from different facilities takes place. LaughterBosses are invited to contact each other as well as the Humour Foundation for ongoing support. A Clown Doctor also attends the initial training day further enhancing local contact. Half day follow-up workshops are held every 3 to 4 months. These are conducted by Clown Doctors experienced in training/teaching and the agenda includes feedback, stories, strategies and further performance training. The workshop gives participants exposure to different performance styles, helps maintain enthusiasm and builds skills. Further training in performance arts such as clowning, juggling and closeup magic is encouraged. A research study looking at the impact of the LaughterBoss on residents, staff and the facility as a whole is underway in New South Wales, Australia. There are numerous research possibilities in this area.

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LaughterBoss Feedback “A sincere thank you for everything, this has been a great opportunity to learn more about myself and my capabilities. I had a blast and so did our staff. The atmosphere at our centre today was amazing, we were full of energy and great ideas.”30

LaughterBosses have said that this new role has given them permission to be silly. They were now looking for opportunities to make someone react and noticed that the simple things worked the best. It was also noticed that when staff join in, morale was boosted for the day. This was accompanied by a domino effect promoting conversation and stimulating interaction. There was great delight in seeing residents and their families laughing together. In closed-ward dementia facilities, reduced challenging behaviours were observed after interaction with the LaughterBoss. The LaughterBoss made a noticeable and positive impact during Quality Assurance assessment for the facility’s accreditation audit. Three questionnaires are given. One immediately prior to the workshop, one at the end of the workshop and one at the follow-up workshop three months later. These are being collated. The most creative challenge is being comfortable with and learning to switch between health professional and LaughterBoss mode. There is recognition of the power of the LaughterBoss to bring about positive change. Unexpected and encouraging developments have been the enhanced linking to the broader community through increased positive media and involvement of local businesses supplying LaughterBoss needs free of charge. 9.

Conclusion

The positive benefits of humour and laughter in the aged care setting have been acknowledged. The “art of medicine” as practiced by the LaughterBoss is alive, well and needed in the aged care sector. The LaughterBoss model is not confined to aged care as it can easily extend to other areas of health care as well as the business/corporate sector. The court jester is present, busy and needed in the new millennium. 10.

Further Reading

Adams P (1998) House Calls. San Francisco CA: Robert D Reed Publishers.

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___________________________________________________________ Fry, William F, and Waleed A Salameh (1987) Handbook of Humor and Psychotherapy: Advances in the Clinical Use of Humor. Sarasota, FL: Professional Resource Exchange. Klein, Allen. (1989) Healing Power of Humor. Los Angeles CA: Tarcher Segal, Bernie S. (1986) Love, Medicine and Miracles. New York, NY: HarperPerennial. Wooten, Patty. (1996) Compassionate Laughter. Utah: Commune-A-Key.

Notes 1

L.S. Berk, S.A. Tan, W.F. Fry, B.J. Napier, J.W. Lee, R.W. Hubbard, J.E. Lewis & W.C. Eby, “Neuroendocrine and stress hormone changes during mirthful laughter.” American Journal of the Medical Sciences. 298(6) (1989): 390-396. 2 K.M. Dillon, B. Minchoff, & K.H. Baker, “Positive emotional states and enhancement of the immune system.” International journal of Psychiatry 15.1 (1985-86):13-18. 3 W.F. Fry “The biology of Humor.” HUMOR: International Journal of Humor Research 7.2 (1994): 111-126. 4 W.F. Fry & Waleed A. Salameh. Handbook of Humor and Psychotherapy: Advances in the Clinical Use of Humor. Sarasota, FL: Professional Resource Exchange, 1987. 5 M. Gelkopf & S. Kreitler “Is humor only fun, an alternative cure or magic? The cognitive therapeutic potential of humor.” Journal of Cognitive Psychotherapy: An International Quarterly, 10(4), (1996): 235-254. 6 The Association for Applied and Therapeutic Humor. www.aath.org 7 D. Mobbs, M.D. Greicius, E. Abdel-Azim, V. Menon, &A.L. Reiss, “Humor modulates the mesolimbic reward centers,” Neuron 40 (2003): 1041-1048. 8 A.L. Barrick, R.L. Hutchinson, & L.H. Deckers., “Humor, Aggression and Ageing,” Gerontologist 30.5 (1990): 675-678. 9 R.A. Dean, “Humor and laughter in palliative care.” J Palliat Care, 13(1), (1997): 34-39. 10 K. Fox, “Laugh it Off: The Effect of Humor on the Well-Being of the Older Adult.” Journal of Gerontological Nursing. 16.12(1990): 1116. 11 W.F. Fry, “Humor, Physiology and the Ageing Process,” in Humor and Ageing, eds. L. Nahemow and K. A. McClusky-Fawcett (Orlando, FL: Academic Press, 1986), 81-98. 12 J.R. Hulse, “Humor: A Nursing Intervention for the Elderly.” Geriatric Nursing 15.2 (1994):88-90. 13 F.A. McGuire & R.K. Boyd, “The Role of Humor in Enhancing the Quality of Later Life,” in Activity and Aging: Staying Involved in

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___________________________________________________________ Later Life, ed. J. R. Kelly (Newbuty Park, CA: Sage Publications, 1993), 164-173. 14 F.A. McGuire, R.K. Boyd and A. James, “Therapeutic Humor with the elderly,” Activities, Adaptations and Aging 17.1 (1992): 1-96. 15 J. Richmond, “The Lifesaving Function of Humor with the Depressed and Suicidal Elderly.” The Gerontologist 35.2 (1995): 271-273. 16 J.J. Simon, “Humor and the Older Adult: Implications for Nursing,” Journal of Advanced Nursing Practice 13 (1988): 441-446. 17 H. Williams, “Humor and Healing: Therapeutic Effects in Geriatrics,” Gerontion 1.3 (1986):14-17. 18 The Humour Foundation. www.humourfoundation.com.au 19 P. Spitzer, “The Clown Doctors,” Australian Family Physician 30(1) (2001):12-16. 20 R. Llewellyn-Jones, “New Approaches for Late Life Depression in Aged Care.” Challenging Depression in Aged Care Conference, Sydney, Australia, 2003. 21 Ibid. 22 Ibid 23 Ibid 24 Hammond Care Group www.hammond.com.au/dsdc/conferences.php?conference=2003 25 Beatrice K. Otto, Fools Are Everywhere. The Court Jester Around The World. Chicago: University of Chicago Press, 2001. 26 Fry, 111-126. 27 Williams, 14-17. 28 Hammond Care Group 29 The Association for Applied and Therapeutic Humor. www.aath.org 30 Physiotherapist Assistant at Bundaberg Blue Cross Aged care Facility, Queensland.

Author Dr Peter Spitzer is a practising medical practitioner in Bowral, NSW, Australia. He is the Co-founder, Medical Director and Chairman of the Humour Foundation. In hospitals he operates as Dr Fruit-Loop dispensing mirth, prescribing smiles and leaving his patients in stitches. Contact: PO Box 1893 Bowral 2576 Australia email:[email protected] www.humourfoundation.com.au

“Nothing seems funny anymore”: Studying Burnout in Clown-Doctors Nicole Gervais, Bernie Warren and Peter Twohig Abstract Using clowns in hospitals can be an effective therapeutic tool. They can help to: • • • • •

distract patients from their pain and illness; provide a humorous escape from the sometimes stressful hospital environment for patients, visitors and healthcare staff alike; calm resistant paediatric patients, enabling staff to perform necessary invasive procedures; reconnect dementia patients with their current surroundings; reduce rehabilitation patients’ need for various medications.

In Windsor, Ontario, Canada, Fools for Health employs clowndoctors in local hospitals and care homes. In addition to running clowndoctor programs, the organization collaborates with academic researchers to examine the outcomes of this work. While a good deal of scientific and anecdotal evidence exists concerning the impact of humour on the recipients, little is known about how working as a clown-doctor affects the performer. Of particular interest to the researchers are the factors that could negatively impact their performance. This paper will describe factors that may create burnout among clown-doctors. It will describe research that has already begun and present a roadmap of future research in this area. Finally, it will also detail methods and approaches used by individual clown-doctors and organisations in working to prevent and counteract ‘burnout’. 1.

Introduction

A clown-doctor (CLDr) is a specially trained professional artist who works in a therapeutic program within a health care or nursing home setting. Unlike clowns who make occasional visits to hospital bedsides to “entertain,” professional CLDrs are skilled and valued members of a clinical team and are therefore an integral component of the treatment process in the settings in which they practice. CLDrs do not provide clinical services but rather they seek to improve quality of life for patients (or residents), their families and the

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___________________________________________________________ healthcare staff who interact with them, and the promotion of both physical and mental health. They accomplish this through the use of interpersonal skills, music, improvisational play and humour. CLDrs are able to accomplish many breakthroughs with patients and nursing home residents. With patients with aphasia, CLDrs have been able to get them to vocalize by involving them in singing or telling jokes. For those in rehabilitation programs, CLDrs have been able to encourage the patients to move the affected limb, or complete more repetitions of a therapeutic exercise. When working with dementia sufferers, clowndoctors are able to encourage reminiscence. And with all populations, CLDrs have shown an ability to relieve boredom, anxiety and to provide a social connection that may not otherwise be present. 2.

Fools rush in

Fools for Health began its first clown-doctor program in Windsor, Ontario, Canada in July 2001 with four CLDrs working on an adult in-patient rehabilitation unit. Since then, Fools for Health CLDrs 1 have worked regular shifts in various local hospitals on oncology, palliative care, complex continuing care, and paediatrics units. They have also worked occasional shifts in emergency, and outpatient clinics and even the operating room. More recently they have worked in several nursing homes and long-term care facilities. 2 Fools for Health was one of the first clown-doctor companies to work across the lifespan, and even today work with adults and the elderly as much if not more than with children. Since its inception, Fools for Health has employed 26 CLDrs. They have ranged in age from their early 20s 3 to their early 50s. Some have worked for a few months while others have worked for almost four years. Some people work only with one other clown partner whereas others have many different partners. Similarly, some CLDrs may work at only one site, while others service multiple areas. At the moment, the makeup of the performers is slightly older and more experienced than in previous years. 4 Unlike other areas that have CLDr programs (e.g. Paris, New York), Windsor is a relatively small centre with precious few opportunities for other creative employment. Consequently, Fools for Health tries to provide full-time employment for its CLDrs and this means that participating CLDrs often work more shifts than many of their colleagues in other organizations. The CLDrs of Fools for Health wear little to no clown make-up, and carry few props. Instead, they are encouraged to work with the items found in the patients’ rooms. These two policies ensure that the visit is an interaction more than a performance; patients can connect better to

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___________________________________________________________ someone who’s clearly still human; and through their personal effects, CLDrs get a better sense of whom they are clowning to. Fools for Health places heavy emphasis upon this interaction between the clowns and the “audience”; patients of healthcare settings, and residents of nursing homes. These interactions are therapeutic in nature, allowing patients to forget about their pain, illness or boredom, and for patients, often easing symptoms or encouraging them to work harder on their rehabilitation. However, these interactions are often quite intense for the clown-doctors; they have to be constantly focussed upon the patient, and yet still remain in character at all times. There are incredible demands on the artists’ creative abilities as well as their empathic skills. Fools for Health has kept detailed records of its programs in order to track its successes as well as determining areas of possible improvement. Through review of these records, and informal conversations between the researchers and the employees, it became apparent that at least some of the clown-doctors have felt the impact of these creative and empathic demands. It was determined that the possibility for burnout did exist in our population and that it deserved further examination. In 2004, Dr. Warren and Dr. Twohig received a national grant to study the work of the clown-doctors. Under the purview of this study, we were able to conduct interviews with 18 clown-doctors to try to seek a more complete picture of which factors may contribute to stress and burnout among clown-doctors. We were also interested in the compensatory behaviours engaged in by the CLDrs. In this study, the participants interviewed were limited to those who have worked or are currently working for the Fools for Health organization. Our belief in the necessity of such research was borne out by others. At the conference where an earlier version of this paper was presented, we received much agreement and encouragement from other attendees who work with CLDrs. Following our presentation, the director of a large, well-established clown-doctor company stated, “I must spend fifty percent of my time preventing burnout in my clowns”. 3.

Burnout

Job burnout develops as a result of prolonged exposure to emotional interpersonal stressors at one’s workplace. Burnout is generally viewed as being made up of three distinct components. 5 The first is a feeling of exhaustion. The person is tired and finds it hard to complete all their daily tasks. They may find it hard to get out of bed in the morning, and may dread going to work. The second component is a gradual distancing of oneself from other people, particularly those individuals who are recipients of your work. Instead of seeing other people as people in their own right, they are viewed only as things to be acted upon. In a

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___________________________________________________________ healthcare setting, the patient becomes an “illness” or an “injury” to be fixed, rather than an individual. It is suggested that this “depersonalization” helps to keep the worker from feeling the other person’s pain. Finally, the third aspect of burnout involves the worker feeling like they are not accomplishing enough; that either the quality or quantity of their work is lacking. Past research has given us some ideas as to the some of the common stressors contributing to burnout. Experiencing a work overload is one contributor 6, as is role conflict 7. In a healthcare setting, a conflict could exist between the worker’s desire to comfort the patient and a need to objectively deal with their illness and perhaps cause the patient additional discomfort (e.g. giving them a needle). Being unsure of their required tasks is another common stressor 8. In addition to the demands placed upon the worker, a lack of resources or opportunities can also contribute to burnout. These include a lack of support from colleagues, lack of support and feedback from supervisors and a lack of control in their work 9. Other contributing factors may include working non-standard shifts 10 (evenings and weekends), having an unpleasant supervisor 11, and being exposed to aggression from clients/patients 12. While burnout is typically related more to situational factors than to personal ones, some individual characteristics have been found to increase susceptibility to burnout. Younger individuals appear to be more susceptible than older workers. Single workers are more likely to experience burnout, as are those with higher levels of education. In terms of psychological characteristics, those susceptible to stress have low levels of hardiness, poor self-esteem, an avoidant style of coping, and those who feel that events in their life are outside their control. 4.

Fools for Health Findings

We approached roughly two-dozen current and former CLDrs to gauge their interest in participating in our study. The protocol consists of an initial semi-structured interview to be conducted one-on-one with the participant. If warranted, a follow-up interview was conducted to clarify points or expand upon areas of interest to the researchers. Only one individual has declined to participate. In addition to the interviews with the CLDrs, we have had an opportunity to conduct interviews with 18 members of the healthcare and administrative staff whom the clowndoctors have interacted with. We did not ask them specifically about stress in clown-doctors, but some spontaneously brought up the issue during the interview. These discussions were included where appropriate. The following are some of the themes that arose from the preliminary analysis of the data. These themes should be considered

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___________________________________________________________ tentative and are likely to change as the analysis is developed and further interviews are conducted. It is also important to keep in mind the importance of individual differences. While some CLDrs found certain occurrences extremely stressful (e.g. receiving a bad reaction from a patient), others were more able to take it in stride. It is hoped that our continuing research will enable us to determine factors that create these differences. A. Clown Partners Generally, the presence of an artistic partner while clowndoctoring can help raise the performance to new heights. Within a “clown marriage” as it often called, the performers receive incalculable support, both the very tangible support of having someone to use in skits or set up punchlines and the more subtle form of support that comes with having someone by your side, allowing the performer to take bigger chances. Despite these benefits, the clown marriage may also be a source of tension or frustration, (e.g. when one of the partners is not seen as performing up to par). The other person may feel like they are doing the work of two people, thereby accentuating (rather than alleviating) the stress on the performer. …when I’m working with a competent clown-doctor, I only have to use my energy…. But when I’m carrying the other person, then I’m using twice as much energy. A second source of tension reported by clown-doctors arose from either too much or too little variety in the clown marriages. When two clowns constantly work with one another, the artistry can stagnate, with the partners falling back upon the same old schtick. Alternatively, when the clown marriages are too “promiscuous” (i.e., there are frequent partner changes), the clowns may feel they are on unstable artistic ground or that they are unable to find their rhythm. B. Sadness Over the Patients Both the CLDrs and the healthcare staff reported that one of the greatest benefits of the clown-doctors’ work is the bond that they form with the patients, particularly the long-term patients. For some patients, this may be the only purely social bond they have, if they don’t receive visitors. For the patients, this bond is a positive thing, but for the performers, it is a double-edged sword. Most feel honoured and fulfilled to touch so many lives, but this sometimes leaves them susceptible to the pain of the patients and their families. In some cases, CLDrs reported feelings of sadness over the deaths of patients whom they had visited on a regular basis. In others, they

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___________________________________________________________ reported feelings of sadness and stress over the deterioration of a regular patient over time. One CLDr reported feelings of distress and helplessness over seeing or hearing patients in pain. The distress the CLDrs felt over patients was compounded if/when a patient reminded the CLDr of someone from their own lives or when the CLDrs empathised too much with the individuals they visited. I lost three people to cancer, and so for me, I’ve done three stints at Oncology...after the last one, I told them, like “I’m sorry, I can’t do this anymore, I just can’t come here anymore, it’s too close to home”…I have been in the spot of the families and I know what they’re going through… Notably, CLDrs may have an advantage over other healthcare support staff. “The {red} nose is the world’s smallest mask” is a basic tenet of clowning. This mask allows them to distance themselves from the suffering of the patient, while still being connected enough to provide a support for them. Many of the interviewees reported this ability to distance themselves to a greater or lesser extent. …I have a great deal of respect for nurses or these people that have to try and maintain their objectivity and they don’t have a nose, you know, because a part of our training is that our nose IS a mask, is a filter, and you can achieve some distance… C. Being Overworked Windsor, Ontario is a small location compared to Paris, New York, Montreal or other cities that host clown-doctor companies. As such, there are fewer opportunities for Fools for Health performers to work outside of their clown-doctor shifts. Fools for Health does its best to provide enough hours to the performers to enable them to make a living. However, this means that they spend more time “in clown” (i.e. performing) than do those in other centres. The clown-doctors have reported being tense, exhausted or frustrated due to being “in clown” for too many hours in a week, or having to work through the holidays. Performing as a clown-doctor requires a great deal of energy; physical energy to perform the schticks or sing the songs and mental energy required to assess the needs of the patient’s, facilitate a positive interaction and develop responses that are humorous, as well as appropriate to the situation. Given the energy requirements of the job, it is not surprising that the clown-doctors can tire if they feel that they are working too much.

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___________________________________________________________ “You start feeling exhausted. Because clowning takes so many different energies at the same time. It takes physical energy, it takes creative energy, it takes emotional energy, it takes your intuitive energy, and it takes your intelligent energy…When you’re using that constantly, for an extended period of time over one week, you become very, very tired. You become very stressed…” D. Getting the Wrong (or No) Information It is crucial that the CLDrs obtain accurate information about the patients. They need to know if there are people who are in isolation and not to be visited, or whether special precautions are needed to prevent contagion. Additionally, in order to be most effective, they need to know if there are any special needs, (i.e. whether the patient is hard of hearing) and what would be most therapeutic to work on (i.e. getting an aphasic person to try to vocalize). When the CLDrs are unable to obtain this information, which is usually provided by the charge nurse, they report feeling very off-balance, which makes it hard to perform properly, and their interactions are not as effective as they could be. It is additionally distressing to the CLDrs when they feel that their inability to obtain notes is due to staff ignoring their presence. While the CLDrs appreciate how rushed the staff are, some reported occasionally feeling as though they were being made to wait longer to receive notes than was necessary. We’ve gone up to collect notes, and we’ve been very polite and stood there waiting for people to get notes, and the healthcare professional who’s giving us notes or some other reason just decide…that we could wait our turn. So we’ve waited…we’ve waited 20 minutes for people to actually pay attention to us, and this was OUT of clown, this was actually trying to get notes. In some cases, the CLDrs are unable to locate someone to get notes from, or were told there were no notes for that day. This sometimes led to tense situations for the CLDrs. you’re walking blindly into a room, and if you don’t get proper census information and you walk in and you do something, and then, oh my gosh, you realize that you just offended the person, that’s pretty stressful too.

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___________________________________________________________ E. Feeling Unappreciated or Disrespected Some CLDrs indicated that they felt the strain of having patients or healthcare staff behaving rudely towards them. While these patients, visitors and staff are often eventually “won over,” their initial resistance can cause great stress to the CLDrs. Some patients and their visitors indicate that the situation is “no laughing matter” and felt that the antics of the CLDrs were somehow mocking them or being disrespectful of their suffering. These individuals may tell the CLDrs to leave, with varying degrees of politeness. …the first room we went into, we had a lady yell at us, and say “this is nonsense, get out of here” and it kind of puts you on guard for the rest of your shift. You’re like “uh-oh” you don’t want that to happen again - nobody likes to be told that, you know, “you’re not welcome” With uncooperative staff, it is possible that they feel that their own position is being mocked or made light of. Others staff have indicated that the CLDrs were in their way or impeding their work. Again, in these cases, the CLDrs may be asked to leave the area or quiet down. Sometime, nothing will be said at the time, but complaints will be made to the administrative staff to then be shared with the CLDrs. In addition to the friction between clown doctors and those receiving and providing care, some of the CLDrs felt unappreciated by the administrative or managerial staff of the organization. This was in a less deliberate manner than the healthcare staff. Some CLDrs could not provide a concrete example of this but indicated that it was an intuitive feeling they had. In other cases, it was a matter of supervisors not having the time to observe their work or provide feedback or that not enough time was given at meetings for CLDrs to present their concerns. And so, you kind of start to wonder, “well, am I good? Am I good enough?” Because you haven’t seen me in so long, and then all of a sudden…[the supervisor] will see for like one shift, and of course that’s your worst day ever. And that’s just like “uh” and then you start thinking, “well, if he doesn’t think I’m any good, is he going to fire me?” and then…“what am I going to do?” and it escalates, like a little domino effect F. Illnesses CLDrs are required to regularly place themselves in positions where they are exposed to various illnesses. At the same time, a chief concern for hospitals is infection control, and individuals with symptoms

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___________________________________________________________ are required to avoid the hospitals. It’s not like other professions where you can come in with an illness and simply suffer through the day. Thus, CLDrs have the dual stressors of trying to avoid contracting an illness from those they are trying to help, and the worry about lost wages if they are unsuccessful at keeping themselves symptom-free. …when you cover a whole hospital, you’re running the gamut of illnesses and diseases…I find it I find it more difficult to concentrate there than I do anywhere else, because I’m…I’m more conscious of the fact that I can really get sick in this place. G. Not Meeting Expectations More than one CLDr reported that a source of their stress involved their expectations for the day. They anticipate having a really good day, with all their interactions going well. When they have an unsuccessful encounter, their frame of mind changes for the worse and it pulls them out of character. H. Performance Anxiety Related to the notion of not meeting expectations is performance anxiety. A requirement of the job is to be able to use improvisation effectively, and some worried about having moments when they go blank and cannot come up with anything. It was also noted that, as with any performance activity, the performer is presenting one’s self to the audience and is therefore left open to criticism and negative feedback. …you’re really putting yourself out there…you’re different, you’re weird, whatever. And so, it’s kind of important to get feedback about that, supportive feedback to help you feel comfortable doing what you’re doing. It should be noted that this stressor did not emerge very often among our performers, and is considered a non-issue by the older clowndoctor companies. G. Extraneous Concerns Several of the participants identified stressors that, though they may occupy a good portion of the person’s thoughts, are not unique to the occupation of CLDr and the participant likely would be encountering the same difficulties regardless of how they were employed. However, it is useful for directors and managers of CLDr groups to be aware of these issues and how they may affect the employee.

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Financial difficulties. The CLDrs reported that when they had concerns about their financial stability, they would find it hard to stay in character. Part of them was focused on how they would make ends meet, and thus weren’t fully focused on the patient or resident. Personal issues. As with financial difficulties, CLDrs trying to work through personal difficulties found that they were unable to fully focus on their clowning. Time management difficulties. In some cases, CLDrs had very little time to travel from one location to another. In these cases, the CLDr felt rushed and uncomfortable in the transition from their own persona to their clowns. Not all of the participants reported extraneous concerns as impacting their work, and in fact, it was remarked that often, clowning allows them a chance to forget these other concerns. 5.

Implications for CLDrs

When a CLDr is suffering from burnout, it affects a wide circle of people; the CLDr themselves, their partner, the patients and visitors, the healthcare team, and the organization for which they work. The first issue for a clown-doctor suffering from burnout is difficulty in adequately getting into character. When a clown-doctor is only half “in clown” (i.e. their full attention is not focused on their artistry or performance), their interactions are not as beneficial as they could be. They may be more concerned about getting through the room than providing therapeutic support. In some cases, they may be less sensitive to the people around them, and unwittingly offend those they are there to help. They rely more on their partner, which in turn places addition stress and strain on this partner. In any environment, burnout can cause absenteeism and employee attrition. Absenteeism is a big concern for CLDr companies, as they must either find a replacement for the performer, or cancel the shift. Finding a replacement at the last minute is a difficult task, but cancelling the shift is a disappointment for the ward they were meant to visit. Too many cancellations and the reputation of the organization may diminish in the eyes of those on the ward. In more serious cases of burnout, the performer may choose to leave the organization and clown-doctoring entirely. Employee attrition is troublesome in any organization, but in such a specialized field as clowndoctoring, this attrition can be devastating to a program. There are very few individuals who embody all the qualities of a good clown-doctor, and they are very difficult to replace.

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___________________________________________________________ Also of concern are the effects of burnout on the individual. Burnout has been found to have a negative impact on health 13. Thus, feeling stressed or being burnt out may lead to the performers developing illnesses, or being more susceptible to the infections that they encounter during their work shift. These illnesses may in turn compound the stress they face through having to take time off work and the resulting lost wages. Burnt out CLDrs have to cope with exhaustion, a reduced sense of accomplishment and feeling like they are not able to truly reach the people they are interacting with. This emotional toll may bleed into their personal lives, increasing the strain they are under. In some cases, the distress increases to such a level that they choose to leave the organization. 6.

Preventative Factors and Rehabilitation

Past research has suggested many different interventions to counteract the effects of stress and reduce or prevent burnout. The most effective of these involve the accurate diagnosis of the stressors and efforts to counteract them 14. That being said, we again turn to the information gathered from our interviews in order to determine what steps the clowns of Fools for Health have taken to buffer their stress. In addition, the information gained allows for an outline of what organizational leaders and managers can do to protect their employees. A. Individual Level As previously mentioned, CLDrs have to utilize a great deal of creative and emotional energy in their work, and they leave themselves open to criticism. As such, they have an emotional need for validation and reassurance. Ideally, they would prefer that it come from a supervisor or other experienced CLDrs, but when this is unavailable, they look for it elsewhere. Usually, they would find it in the comments from patients, their visitors or the healthcare staff. “Because when you see the light in a little kid’s eyes, for example, or a little man just sitting there all lonely and things, and all of a sudden, he smiles at you, you’re like, “oh good”. And when you hear from people like “where have you guys been? We’ve missed you, we love you,” you’re like “this is why I do it. This is why I come to work every day. This is why I put on this red nose every day.” That does really, really help a lot. Because you do feel appreciated.”

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___________________________________________________________ Positive social interactions were also identified as a stressmoderating factor. These included both interactions with those met during the course of a workday (co-workers, patients, staff) and interactions in one’s personal life (time spent with friends). This finding is in keeping with studies on social interaction. 15 The characteristics that make a performer a good CLDr may also help them prevent burnout. Research into humour and laughter has indicated that it can be an effective tool for coping with stressors in one’s life 16, 17. The CLDrs are adept at creating humour, and tend to maintain an outlook on life that enables them to see the humour in most situations. Many of the CLDrs actually engaged in joke-telling when describing the stressors they faced, indicating a tendency to utilize this coping mechanism. Of special interest is the number of respondents who reported that the stressors identified did not have an impact on their clowning because of the clear distinction between their own personality and their clown character. To these individuals, getting into clown involves a shift in their perception of their self. For these individuals, the stress is on the performer and not their clown character and, as a result, their clowning is not affected. “…going to work and becoming another person actually is a stress reliever…when I’m in clown, I’m not thinking about my own problems…” In addition to having more protection against stress, it was noted by the researchers that those who more clearly delineated their own personality from the clown character were arguably the most effective performers (i.e. they are most able to put the patient first and choose an appropriate interaction). B. Organizational Level Ensuring adequate training of the CLDrs may also help to stave off burnout. Training helps to refine needed skills, as well as increasing the performer’s repertoire of songs and activities, both of which increase the performer’s sense of accomplishment. A large repertoire also helps to prevent stagnation. Well-trained performers avoid being a strain on their partner. In addition, holding training sessions as a team helps to build bonds and encourages positive social interactions within the team. However, we are still faced with the question of what constitutes adequate training. It is hoped that the answers to that question will be found through the course of the larger study and it is clear that the well-being of performers needs to be one component of training efforts.

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___________________________________________________________ One suggestion brought up by both the CLDrs and the healthcare staff was to make mandatory debriefing/counselling part of the CLDrs normal work. One member of the healthcare team likened the work of the CLDrs to that of chaplain; being available to support and comfort those facing serious illnesses and death. With the need for confidentiality that accompanies working in the hospital, which limits how much can be disclosed to their social supports, the clown-doctors have a need for someone to air their concerns. Making the time mandatory ensures that those who are too proud to seek help on their own will be able to be debriefed. Other suggested mechanisms to help support the CLDrs and ease strain include; encouraging the performers to keep a journal of their experiences, and encouraging them to engage in physical activity (yoga was a leading favourite among our employees). These were activities noted by CLDrs as being beneficial in managing stress, and encouraging new CLDrs to do the same is expected to help them as well. 7.

Areas of Future Study

As mentioned earlier, aspects of the clown-doctor work that caused great stress for one performer didn’t faze another. Further study would be beneficial in determining which individual characteristics help to mediate these attributions. To interest to the researchers are the following demographic characteristics; age, training, relationship status, and performance experience. As mentioned previously, our research was limited to the work of the Fools for Health organization. Thus, the participants were fairly homogenous in terms of language, culture and location of work. Future study with other groups will enable us to determine the effects of culture on the work of the clown-doctors. In addition, these other groups differ in terms of length of program, populations worked with and relationships with the healthcare team. As such, it is supposed that their experiences will be different, including the stressors that they faced and the methods they utilize to combat them. 8.

Conclusion

The material analyzed to date has already given us valuable insight into possible stumbling blocks for performing CLDrs. While some are intrapersonal (performance anxiety, fear of illness) a good deal are the interpersonal stressors classically identified with burnout. These interpersonal stressors occur on three levels of interaction; with their “clients” (the patients or residents and their visitors), the healthcare staff and the CLDr organization who employ them.

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___________________________________________________________ The study has also taught us about the self-directed attempts made by the CLDrs to combat the strain and maintain the requisite high level of performance. While most of the performers have been relatively successful in their attempts, there have been individuals who have chosen to leave the organization due to the stress they were under. Further study may help us to identify precursors to this attrition and prevent it. In time, we hope to use the information gained about possible areas of burnout to help prepare CLDrs for their work and to make them more effective for patients, their families and the healthcare team.

Notes 1

The CLDrs of Fools for Health all have their own unique personalities and performance strengths, with some being exceptional singers and dancers, while others are captivating storytellers. All, however, are adept at improvisational humour and clowning in a medical setting. All Fools for Health clown-doctors wear red noses and white lab coats, but no traditional clown make-up. They always work in pairs, providing support for each other and widening the scope of material that can be utilized. They carry very few props, and instead make extensive use of improvisation, drawing upon anyone and anything in close proximity at the time. They are able to work in a wide variety of styles (i.e. quiet singing or talking, or loud, boisterous schtick) and all are able to determine what style to adopt for each individual they interact with. 2 Outside of hospitals, CLDrs who work with individuals in a nursing home setting often shed their white coats and stethoscopes and “age” their characters. This variation is referred to as familial clown. These characters employ a lot more music and storytelling and use relatively little “medical schtick”. Also, as many of the residents suffer from cognitive difficulties, the activities of these familial clowns are often geared towards maintaining and improving cognitive functioning. 3 In the first 2 years, many of Fools for Health’s CLDrs were also students or recent graduates of the Arts program, and had Dr. Warren as a professor or advisor. 4 It is interesting to note that few if any of the current CLDrs were ever students of Dr. Warren, the Director. We are hoping to interview many of these former clown-doctors, whom in general were younger, arguably less experienced and held previous ties to the “head fool” Dr. Warren in order to obtain insight into their unique experiences. 5 C. Maslach, “Job Burnout: New Directions in Research and Intervention,” Current Directions in Psychological Science 12 (2003): 189-192.

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Maslach, 189. C. Fernet, F. Guay, & C. Senecal, “Adjusting to job demands: The role of work self-determination and job control in predicting burnout,” Journal of Vocational Behavior 65 (2004) 39-56. 8 Fernet et al, 39. 9 C. Maslach, W.B. Schaufeli, & M.P. Leiter, “Job Burnout,” Annual Review of Psychology 52 (2000): 397-422. 10 M. Jamal, “Burnout, stress and health of employees on non-standard work schedules: a study of Canadian workers,” Stress and Health 20 (2004): 113-119. 11 M.P. Leiter, & C. Maslach, “The impact of interpersonal environment on burnout and organizational commitment,” Journal of Organizational Behavior 9 (1988): 297-308. 12 S. Winstanley & R. Whittington, “Anxiety, burnout and coping styles in general hospital staff exposed to workplace aggression: a cyclical model of burnout and vulnerability to aggression,” Work & Stress 16 (2002): 302-315 13 Maslach et al, 397. 14 S. Innstrand, G. Espnes, & R. Mykletun. “Job stress, burnout, and job satisfaction: An intervention study for staff working with people with intellectual disabilities,” Journal of Applied Research in Intellectual Disabilities, 17 (2004): 119-126. 15 F. Tschan, N.K. Semmer & L. Inverson, “Work related and ‘private’ social interactions at work,” Social Indicators Research, 67 (2004): 145-182. 16 M.H. Able, “Humor, stress and coping strategies,” Humor 15(4), (2002): 365-381. 17 Martin Fuhr, “Coping humor in early adolescence,” Humor, 15(3), (2002): 283-304. 7

Authors Nicole Gervais, M.A. Research Associate, University of Windsor, Windsor, Ontario, Canada Bernie Warren, PhD. Professor, University of Windsor, Windsor, Ontario, Canada Peter Twohig, PhD. Associate Professor, Dalhousie University, Halifax, Nova Scotia, Canada

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Expressing Sensibilities: Healing Functions of Humour in Palliative Care Ruth Anne Kinsman Dean Abstract Humour does not cure cancer nor is it a panacea for enduring the challenges associated with living with a terminal illness. Despite these limitations, humour has healing capacities, even in the presence of death and dying. This chapter presents findings from a clinical ethnography, which examined humour and laughter among patients, families, and interdisciplinary care providers in an inpatient palliative care unit. Research on humour in other areas of health care consistently reports that humour should be avoided at times of crisis, serious discussion, high anxiety, and dying; all circumstances which are commonplace in palliative care. Regardless of this caveat, humour and laughter were pervasive in the research setting. Humour helped to build relationships, contend with difficult circumstances, and express sensibilities. Patients used humour to communicate messages too painful to be spoken aloud. Sensitive and intuitive care providers seemed to know how to respond, whether by reciprocating in kind or using the opportunity to initiate serious discussion. As patients encountered losses in independence, caregivers employed humour as a means of preserving dignity and expressing regard for personhood. Humour served healing functions and proved a powerful asset to therapeutic relationships. In palliative care, as elsewhere in health care, it is important and should not be disregarded nor considered trivial. 1.

Introduction

“The essence of humor is sensibility, warm, tender, fellow-feeling with all forms of existence.” (Carlyle) Sensibility refers to a delicacy of perception about the aesthetic or emotional state of another. When one expresses sensibility, he or she demonstrates regard for another’s self as a fellow human being and the uniqueness of each person. Can it be that this is the essence of humour? How does that relate to healing? This paper addresses these issues, drawing upon the findings of a clinical ethnography in which the author explored humour in the context of an inpatient palliative care unit. Clinical ethnography is intended for examination of the human experience of illness or of care-giving in an

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___________________________________________________________ interpersonal context1. The method emphasizes the subjective experience and the realm of communication and interaction for both patients and caregivers. Data were collected through more than 200 hours of participant observation with caregivers, informal interviews with patients and families, and semi-structured interviews with members of the healthcare team (n=15). The idea of healing in a palliative care setting seems unlikely if one thinks of healing merely as curing disease. Patients in this research all had an advanced terminal illness. Not one of them survived more than a few weeks beyond the 14 weeks of the research period. Through the lens of the medical model, which focuses on the biological self and views healing as overcoming disease, no one was healed. 2.

Literature Review

Research has addressed the role of humour in physiological healing with mixed results. One recent appraisal suggests that, to date, there has been little conclusive evidence of the enduring effects of humour on physical healing2. However, research persists. Several current studies suggest that humour and/or positive affective states are related to health. In a study of the divergent effects of laughter in response to humorous entertainment3, there was evidence that laughter increased circulation to endothelial tissue in a manner similar to the benefits of physical exercise. A longitudinal study of Catholic nuns over a 60 year period suggests that participants who demonstrated more positive emotional content in their writings at age 22 years were prone to experience greater longevity.4 A study of physiological correlations between states of happiness and biologic processes (n=216) found an inverse relationship between heart rate, cortisol output, and happiness levels.5 The suggestion is that humour and positive affective states are associated with better health. When healing is considered holistically, the focus widens to include not just bodily health, but also the health of other aspects of the person. To heal is to bring various levels of one’s self (physical, intra and interpersonal, emotional, and spiritual aspects) into new relationship with one another, thus developing a sense of self-integration.6 In terms of intrapersonal and interpersonal benefits, other researchers identify the benefits of humour in communication, human relationships, and as a coping strategy in difficult circumstances.7-12 It is in these contexts that expressions of human sensibility assume healing potential. Socially, smiles and laughter signal friendliness, relaxation, and group cohesiveness.9 Psychologically, a sense of humour provides a stress-mediating variable and serves as a coping mechanism in challenging situations.13 Humour serves as a “status equalizer”, and tends to lessen

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___________________________________________________________ awareness of hierarchical differences in social and professional relationships.14-15 In terms of communication, humour often provides an innocuous means of speaking a message, raising concerns, or distancing one’s self from topics too difficult to address directly.16-20 3.

Research Findings

The tone was set for the significance of humour from the first day of field work when I encountered a team member who had a story of the profound importance of humour, both in physical recovery, and more holistic healing. Upon introduction I was greeted with this fervent message, “There is something very important that I want to share with you”. In the privacy of his office, Ian told his story. Years ago, as a young man, he had encephalitis. He was airlifted to a distant city for treatment. He does not remember the transfer or the early days of his illness. As consciousness returned, he was aware of intense pain, feeling foggy, drifting in and out, and terrible depression, nearing despair. In the next bed was a middle-aged man who was recovering from a stroke. Each time Ian struggled to consciousness, his roommate would speak with him, consistently offering goodnatured and humorous anecdotes as well as encouragement. The anecdotes were always funny, but never ribald or in bad taste. Ian came to see those moments as his lifeline, a reason for fighting back to consciousness and the world of the living. He now believes that this was what gave him the strength to endure the pain and depression and to fight back toward recovery. He has remained ever grateful to that man and to the profound effect he had on his life. Field Notes 3 Ian’s deep respect for the value of humour was evident in the reverence with which he told the story. The sensibilities shared by his roommate contributed to psychic healing, which gave him the strength to reach toward physical healing. Patients who participated in this study were each in their final weeks, and were not physically healed. Humour, however, enhanced the human experience of their dying days in terms of relationships, affective and psychological changes so profound that they could justifiably be described as a healing force. Subsequent sections describe the context and functions of healing humour in the setting.

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___________________________________________________________ A. It’s All About Relationships …it's all about connectedness and relationship and you never know which relationship and which moment of connectedness is going to make a difference, but…it's the humour that is sort of like the glue that helps you put the connection together. Interview 1 Humour most commonly occurred in the context of relationships. In relational interactions between and among patients, families, and care providers, humour inevitably arose and sensibilities were expressed. Responding to physical, emotional, spiritual, and family dimensions of care are hallmarks of compassionate care for the dying, and necessitate relationship. Care providers come to know patients and families to a degree of involvement beyond many conventional care settings. Staff identified relationships as one of their most significant sources of satisfaction. Several described their work in Palliative Care as a privilege. It’s a privilege to work here, I feel that I receive at least as much as I give, more maybe . . . I get their experience, their wisdom. All of that adds to who I am. Interview 8 It’s being involved with patients and families that I like about working here. Interview 6 Similarly, a patient noted the importance of reciprocity, giving and receiving. “I’ve always really enjoyed humour. It helps me get through the days. But it must be reciprocated.” Field Notes 2 Some staff members used gentle humour “up front” to put patients at ease and establish rapport. As one nurse described: As long as they’re not in pain or distress, I like to start lightening it up right off the bat, I’ll tease them, maybe flirt a little bit, get them to smile, get them to thinking this place isn’t so bad after all. Interview 4 In contrast, others waited until there was some rapport before attempting humour. On the day of Mrs. Z’s admission to the unit, she was obviously critically ill. The nurse (Sebastian) was pleasant, supportive, but there was no humour in their interactions. Field notes written the next day revealed that communication had evolved to include gentle humour in the form of teasing.

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___________________________________________________________ Mrs Z's infusion pump is beeping for the 4th time. Sebastian goes into the room to tend to it and comments to Mrs Z. “I think you were playing with these buttons and the machine beeped on you'” (gentle tone, twinkle in his eye). Mrs Z: “Not me, I don't play with that thing and I would never admit it if I were!” Laughter. Sebastian chuckles “Ohh, that was a quick one!” Field Notes 19 Having sensed that Mrs Z would be receptive, Sebastian trusted himself to try some gentle teasing. The result was a warm and therapeutic connection that thrived throughout the few remaining days of Mrs Z’s illness. Whether building or following rapport, humour forged and enhanced relationships. The significance of relationships and respect for personhood is well supported by other researchers. Ferrell applies feminist ethics to the care of persons in pain, suggesting that it is in relationships that we become most fully human.21 Demonstrating respect, relationship, and compassion are central to caregiving. Findings from this research suggest that humour is also connected with relationship, compassionate care, and respect for personhood. This is further reinforced by a study that found a positive correlation between the use of humour and empathy.22 The investigator suggests that the correlation is best understood as emotional intelligence. Emotional intelligence is the ability to understand and control one’s emotions as well as understanding the emotions of others. In the case of palliative care, humour involved reciprocity, establishing and strengthening relationships, and communicated empathic concern. Under such circumstances, humour assumed healing proportions. B. Acknowledging Personhood Team members spoke about their desire that patients and families perceive them as people, and not merely caregivers. When they introduced humour into their interactions, communication became more personal. Patients who responded in kind entered the “two way street” which acknowledged personhood, both of the caregiver and the cared-for. In the words of one participant, …humour allows you to be a person to be able to connect, and that allows you then to move into those places and be genuinely caring…it's the joking that I use to connect with everybody, and at a person- toperson level… Interview 1

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___________________________________________________________ The significance of humour in appreciating personhood came alive in the observations of a patient’s wife. She noted that when care providers shared humour with her and her husband, she felt that they were “seeing them as people” and not merely recipients of care. Continuity of self refers to the sense that the essence of who one is remains intact despite the dubious identity of a patient with advancing illness. In palliative care, acknowledging personhood is particularly salient. The risk is that individuals may “perceive that their personhood or worth has been reduced merely to the context of their illness and its encumbrances”.23 Cohn discusses the significance of Buber’s I-Thou and I-It relationships in terms of physician-patient relationships.24 When a caregiver fails to relate with a patient as one human being to another, the relationship is one of I-It, and both individuals are reduced to abstractions or categories. When caregiver and patient relate as unique individuals, recognizing one another’s humanity, it becomes an I-Thou relationship. Such relationships are characterized by spontaneity, reciprocity, acceptance, and confirmation of otherness. In such relationships, humour is common, personhood is recognized, authenticity is promoted, and the possibility for humanity and healing are present. Observations generated vivid illustrations of varied humour expressions and preferences amongst both staff and patients. There were patients who generally preferred humour as a way of being and introduced it into most interactions. In the case of another family, humour was not considered appropriate, “we don’t choose to deal with things in that way”. In between were those persons who expressed that they had once enjoyed humour but found they were no longer able to appreciate it. Their sense of anxiety and loss superseded their inclination to laugh or respond to humour. Team members displayed great sensitivity in situations where they perceived that humour was not welcome. Several told me that they “just knew” when to use humour and that they were scarcely aware of thinking about it at all. This is consistent with suggestions in the nursing literature that sensitivity to the human dimension of illness and suffering is embodied knowledge.25 Unlike disembodied knowing which is based on scientific knowledge, embodied knowing comes from individual humanity. Embodied knowing was displayed by one nurse who expressed that he didn’t know how he knew when to use humour, “it just comes out”, and another who referred to knowing when to use humour as a kind of “unknowing”. The importance of authenticity was evident in discussions with caregivers. When asked if they could comment on circumstances where humour did not work or was misunderstood, several commented that if they were genuinely caring, and truly authentic in the relationship, misunderstandings were less likely. Even if caregivers “put their foot in

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___________________________________________________________ their mouth”, they were unlikely to harm the relationship under these conditions. Those who introduced humour before establishing a genuine connection were sometimes misunderstood and gave offence. Participants stressed the importance of being sensitive, watching for cues of receptivity to humour, and being aware of circumstances where it might not be appropriate. C. Preserving Dignity “An inability to control basic human functions, especially urination and defecation, seriously threaten a patient’s dignity and violate one of the most basic foundations of adult personhood”.26 Powerlessness over bodily functions is a constant source of potential humiliation. Unfortunately, terminal illness is frequently accompanied by skin breakdown and/or incontinence. Caregivers who were able to share gentle humour in such circumstances helped to neutralize the assault on dignity. One nurse told a story of an elderly gentleman who required help to toilet himself. Displaying a deeply ingrained reluctance to be dependent, he refused to allow his daughters to assist him. The nurse, sensing the tension, approached him gently, asking, “May I have this dance?” Gently, she guided him to his feet and assisted him to the bathroom. Returning him to bed, she thanked him, “that was the nicest waltz I’ve had in a long time”. The daughters quickly picked up on the theme, “Dad, will you waltz with me too?” Interview 4 By the time of death, the sense of life as a dance provided a gentle metaphor, which transformed the indignity of dependence into the beauty of the last dance. Another patient, experiencing incontinence, was deeply humiliated and embarrassed. The nurse who comforted her with the comment, “what goes in must come out” broke the tension and neutralized some of the dismay. The focus became not the unpleasant task of dealing with feces but sensitive regard for preservation of the patient’s sense of worth. I observed another occasion when a patient introduced humour in an embarrassing situation. Mrs. A was an elderly woman with a delightful light-hearted nature and appreciation of humour that even terminal illness could not quench. Mrs. A is conversing with a nurse at the desk. She had been asked to provide a stool specimen. For the third

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___________________________________________________________ day in a row, she has collected a sample in the evening. The problem is that the lab closes by 2pm and they need a fresh sample. The nurse explains that she will need to try again tomorrow earlier in the day. Mrs. A. shrugs her shoulders and grins “I don't know if I can do that. I’ll try but it’s hard.” Sensitively, with a twinkle in her eye, the nurse acknowledges that is hard to "poop on demand". Mrs. A giggles like a girl and agrees. Field Notes 15 Mrs. A was in a frustrating situation. It would have been understandable for her to rage at the inflexibility of an institution that demanded that specimen be delivered by 2pm. Acknowledging the awkwardness with levity and good humour helped to defuse the frustration and reinforced a sense of understanding and relationship with her caregiver. A study with dying cancer patients reported that humour from patients served a similar function in preserving dignity.27 Patients who had wounds that eroded the intact body used humour as a kind of stigma embracement. By using humour, patients were able to take some distance from the betrayal by their bodies, transforming betrayal into an objective subject that could be taken more lightly. Incontinence and erosion of the intact body are so unpleasant that they are rarely addressed publicly. The frequency with which such indignities occur in persons who are dying makes such topics harder to avoid. Humour provides a means of detachment and non-identification that liberates some of the humiliation. In a unique juxtaposition, scatological humour, often frowned upon as undignified, takes on a significant role in preserving dignity. D. The Hidden Message Humour can be an indirect means of expressing a message or unspoken concern. In palliative care, where concerns about death and existential matters often arise, humour was useful for testing another’s receptivity to serious discussion. As one participant commented, “often what people joke about are the tragedies that are in them”. Astute staff learned to listen for such cues, and respond with openness to deeper conversations about what might be troubling patients and families. Other times patients used humour to communicate indirectly that they understood the seriousness of their illness. One nurse told an amusing story about admiring an expensive recliner chair with an electric lift feature that a woman had brought with her upon admission. When

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___________________________________________________________ the nurse commented on how fortunate she was to have such a beautiful chair, the lady responded that it had come from Juan’s Furniture Store, famous for “Don’t pay a cent for 2 years’ financing”. With a twinkle in her eye and a mischievous smile, she quipped: “I’ll never have to pay for this chair!” Interview 9 The message was clear, she knew she would not live much longer, and she was prepared to be light hearted in the face of the inevitable. For persons unaccustomed to associating with those who were dying, such comments can take them off guard, leaving them grasping for appropriate responses. For those familiar with talking about death and dying, there was no discomfort. The message that they were receptive to further discussion was communicated in their open and often laughing responses. As patients and families acknowledge the reality of approaching death, they often experience anticipatory grief, which allows for time to prepare for the loss and for attending to matters left unresolved. In this context, reconciliation of past hurts and areas of unforgiveness often arise. One family member shared a story of humour as a vehicle for reconciliation, communicating forgiveness and understanding in a moment of deep healing. After her troubled adolescence, she remembers her mother’s time in palliative care as one of the most precious times in their relationship. Her mother became increasingly relaxed and amusing and they enjoyed a lot of joking. Her mother tended to hallucinate while on heavy doses of drugs. One night after a particularly entertaining hallucination, she said to her daughter: “If I had known you were having such a great time when you were taking drugs, I would have been more understanding.” Field Notes 13 For this mother and daughter, joking about their experiences with drugs was a healing of the past, an opportunity to laugh together about what had been a stressful and difficult time in their lives. The unspoken message that the past was forgiven offered comfort and healing. When people are in their last weeks of life, it is often assumed that sexuality is not a matter of major concern. Caregivers rarely include sexual concerns as part of their assessment nor do they commonly raise the topic for discussion. For some, however, concerns about sexuality are not extinguished by the presence of terminal illness. In the case of one patient, humour proved an effective way of raising what was on his mind.

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___________________________________________________________ One of the medical residents who recently did a rotation on Palliative Care was young and particularly attractive. She dressed in fashionable clothes that accentuated her curvaceous physical attributes. One evening a middle-aged gentleman who has resisted admission and was unhappy about being there was admitted. This resident had visited him late in the evening. In the morning, the patient asked, "How many doctors are there here”? “Three”. “Who are they”? “Diego, Spanish accent.”…“Not him.” “Julie, lady with blonde hair.”…“Not her”. “Ruby.”…“Is she shaped like this”? He gestures shapely curves with his hands. “Yes, that would be the one”. “When I saw her I found out that I wasn't as bad off as I thought. I’m not dead yet. My eyes nearly popped out of my head! I just needed to know I wasn't dreaming”. Field Notes 9 Men are more likely to use sexual humour, both as a means of enjoyment and a means of conveying disappointment concerning sexuality.28 The ravages of advanced illness often compromise normal sexual function. In this circumstance, sexual humour was a means of communicating disappointment. A sense of loss around sexuality combined with acknowledgment of the seriousness of the diagnosis is a communication too powerful to be missed. Caregivers who responded with compassion could not eliminate the problem but communicated caring and acknowledgment of the patient’s suffering. The potential for healing through self-integration was present in their sensibilities. E. Humour as Respite: Transforming the Moment/Transcending Circumstances The idea that humour provided a moment of reprieve from the realities of illness was illustrated numerous times throughout the data. Often the stories were about a brief burst of laughter and forgetting about illness that transformed the moment. On other occasions, the power of the incident lingered long after the time had passed. Humour not only transformed the moment, but remained in memory or experience in a way that surpassed the ordinary. This was humour that went beyond the normal limits of a circumstance, and retained a sense of power that lingered. It happened once on the night shift. The patient was desperate for a smoke. It was 5am, he couldn’t sleep, he knew he didn’t have much time left and more than anything else he just wanted one last cigarette. His condition was so poor he couldn't tolerate even sitting

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___________________________________________________________ up in a wheelchair so they said “What the heck, we’ll take you in your bed”. As they were pushing the bed down the hall, they encountered another patient pacing the hall. She asked where they were going. “Out for a smoke.” “Can I come?” “Sure, just hop on here”. Hop on she did and settled in at the foot of the bed. Further down the hall, they encountered the night supervisor making her rounds. She took a look, shook her head and commented, “I’m going to pretend I can't even see whatever it is that’s going on here”. They couldn’t help but giggle as they wheeled the bed to the elevator, rode downstairs and outside on to the patio, carefully positioning the bed so everyone could see the eastern sky. Each found a perch on the bed and each enjoyed a cigarette. The sky began to turn light. There was a wonderful feeling of togetherness and peace, a bittersweet time of joy and farewell. It was the last cigarette that man ever smoked. Field Notes 23 The transcendent nature of the event was evident by the tears in their eyes as the participants told the story. No single detail makes the story funny. Yet the expression of sensibility and good humour with which it occurred lingers long past the event. The subtlest of humour continued to evoke an emotional response, indicative of its enduring impact. Other researchers29,30 support the idea of humour as respite. Humour offers an opportunity to step aside and creates a break, even in serious circumstances. It provides a moment of rest which allows for momentary forgetting of unpleasant things. No other references were found, however, that referred to the capacity of humour to transform or transcend circumstances. This may be related to the uniqueness and heaviness of the setting. Humour could not alter the reality of terminal illness but it could offer a moment of forgetting. The contrast between the heaviness of the situation and the flash of illumination that accompanied humour was enough to radically change things, sometimes briefly, sometimes in more profound ways that persisted. F. Humour as Survival In varied ways, several patients expressed that humour was deeply important to their way of being in the world. They spoke of humour as an integral part of their survival, despite illness and pain. Upon admission, Mrs. HP reports that she has had severe pain down her right buttock and leg for three years despite chemotherapy and radiation. She has

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___________________________________________________________ not been able to lie down or sleep in a bed for more than a year. Despite this, she is a pleasant looking middle aged woman, plump, smiling. Dr: “So you've had pain for 3 years? How have you survived and still maintained such a good sense of humour?” Mrs. HP: “It's because of the sense of humour that I've survived. Without that I wouldn't still be here.” Field Notes 16 Survival is an important concept when you are expecting to die. Victor Frankl writes of the profound importance of humour during his internment in a concentration camp, describing humour as one of the “soul’s weapons in the fight for self-preservation.”24 Similarly, prisoners of war in Vietnam considered humour so important that they would risk torture to tell a joke through the prison walls to a discouraged comrade.31 Humour was likened to a fighting back posture, a way of taking control over one’s reaction in circumstances where there was no control over the situation. Persons with a terminal illness often fear the possibility of pain, suffering, and being a burden on others more than they fear death itself. Humour as survival finds its place, not in the ultimate survival of avoiding death, but in surviving the dying process. In the words of comedian Woody Allen, “It’s not that I’m afraid of dying, I just don’t want to be there when it happens.”32 G. When Mundane Becomes Profound Several times it was observed that things that some might consider trivial or childlike, like playing with bubbles or wind-up toys, were accorded great meaning by patients and care providers. A physician gifted an elderly Asian patient with a stuffed bear. Herself a lover of stuffed animals, she sensed that it would be a comfort. The patient received the gift with pleasure, immediately named it Hope, and held it lovingly thereafter. In response to a visitor’s comment about the bear, the patient explained, “I have Hope, I hold Hope in my arms.” Field Notes 17 A gift of a stuffed animal would, for some, be inappropriate. In this situation, introduced with sensitivity and kindness, it became a kind of talisman, a symbol of hope, to be held both metaphorically and physically.

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___________________________________________________________ H. Humour at the Death Bed Other researchers33-36 have reported that humour may be perceived as insensitive or inappropriate in circumstances of a serious nature involving anxiety, crises, and grief; circumstances which frequently arise at the time of death. In interviews, care providers were asked if there was ever humour at the deathbed. Several answered that they had seen humour even in the final moments when the last breath was drawn. They emphasized, however, that such humour was initiated by family members, and not by care providers. “. . . in their last minutes of life I've seen humour used there too . . . it's very loving humour, it's kind of heart- to- heart humour from a family member to the one who is dying.” Interview 8 Initiated by families, the humour was gentle, loving, and personal, focused on memories of the one who was passing. Sensibilities were evident and the potential for healing lingered, even in the last moments. I. Knowing When and How Care providers, when questioned, identified that they instinctively knew when not to introduce humour. Articulation of how they knew was more difficult, consistent with the idea of embodied knowledge that includes sensitivity to the human dimension of illness and suffering.37 Several identified intuition as a trait that helped them to know when to introduce humour into interactions with patients and families. When probed more deeply, each were able to identify a constellation of cues which helped them to assess receptivity and determine appropriate timing for humour. Cues included observation of receptivity to innocuous attempts at light-heartedness, visual cues, particularly expression in the eyes, and assessment of circumstances. Intuition supplemented the wisdom of experience, the deliberateness of assessment, embodied knowing, and innate sensitivity. 4.

Significance

Humour has often been taken for granted, so ubiquitous that there has been no sense of urgency for research. Evidence-based care has become the gold standard for identifying optimal healthcare practice. With the maturing of palliative care as an area with a distinct body of expertise and knowledge supported by research, the time has come for exploring the significance of humour. This study establishes its significance, not merely

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___________________________________________________________ as a taken-for granted appendage, but as an identifiable component of compassionate, person-centred care for the dying. The value of humour resides, not in its capacity to alter physical reality, but in its capacity for affective or psychological change that enhances the humanity of the experience. Humour is significant in enabling human connections. At its best, humour conveys a sense of regard for another, a sense of dignity and respect. In health care, caring is considered by many to be a core concept, shared by all of the professions. Others suggest that caring is too limited, non-substantive, non-generalizable, anti-intellectual, and too sentimental to have theoretical significance.38 Overplaying the theoretical significance of humour could lead to similar charges. Sensitive use of life-giving humour cannot replace scientific knowledge or objective data related to health or illness, but its potential as a powerful adjuvant should not be overlooked. This research demonstrated a positive relationship between sensibility, humour, and healing in care of the dying. More evidence will be needed to further understand this relationship. Meanwhile, practitioners, educators, and researchers should not overlook what has been learned. Care providers need to trust their instinctive sense of knowing when and how to use humour. Responding to patients and families in human-to-human interactions will naturally include humour, which should not be repressed or overshadowed by technology. Its humanizing potential, life-giving capacities and healing properties are too important to be ignored.

Notes 1

Arthur Kleinman, “Local Worlds of Suffering: An Interpersonal Focus for Ethnographies of Illness Experience,” Qualitative Health Research 2 (1992): 127-134. 2 Rod Martin, “Humor, Laughter, and Physical Health: Methodological Issues and Research Findings,” Psychological Bulletin 127 (2001): 504-519. 3 Jennifer Warner, “Laughter May Build Healthy Blood Vessels”, WebMD Medical News, 7 March 2005, (March 10, 2005). 4 Deborah Danner, David Snowden and Wallace Friesen. “Positive Emotions in Early Life and Longevity: Findings from the Nun Study.” Journal of Personality and Social Psychology 80 (2001):804813. 5 Andrew Steptoe, Jane Wardle and Michael Marmot, “Positive Affect and Health-Related Neuroendocrine, Cardiovascular, and Inflammatory

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___________________________________________________________ Processes,” Proceedings of the National Academy of Sciences of the United States of America 102 (2005): 6508-6512. 6 Melodie Olson, Healing the Dying, Toronto: Delmar, 1997. 7 Alison Langley-Evans and Sylvia Payne, “Light-hearted Talk in a Palliative Day Care Context,” Journal of Advanced Nursing 26 (1997): 1091-1097. 8 Linda Henman, “Humor as a Coping Mechanism: Lessons from POWs,” Humor 14 (2001): 83-94. 9 Peter Berger, Redeeming Laughter: the Comic Dimension of Human Experience, New York: Walter De Gruyter, 1997. 10 Cheryl Beck, “Humor in Nursing Practice: a Phenomenological Study,” International Journal of Nursing Studies 34 (1997): 346-352. 11 Paivi Astedt-Kurki, Arja Isola, Taja Tammentie and Ulla Kervinen, “Importance of Humour to Client-Nurse Relationships and Clients’ Well-Being,” International Journal of Nursing Practice 7 (2001): 119-125. 12 Paivi Astedt-Kurki, and Arja Liukkonen, “Humour in Nursing Care,” Journal of Advanced Nursing 20 (1994): 183-188. 13 Herbert Lefcourt, Karina Davidson, Robert Shepherd, Margory Phillips, Ken Prkachin and David Mills, “Perspective-taking Humor: Accounting for Stress Moderation,” Journal of Clinical and Clinical Psychology 14 (1995): 373-391. 14 David Goldberg, “Joking in a Multi-disciplinary Team: Negotiating Hierarchy and the Allocation of ‘Cases,’” Anthropology & Medicine 4 (1997): 229-244. 15 William Yoels, and Jeffrey Clair, “Laughter in the Clinic: Humor as Social Organization,” Symbolic Interaction 18 (1995): 39-58. 16 Langley-Evans, 1091-1097. 17 Henman, 83-94. 18 Berger, 1997 19 Beck, 346-352. 20 Astedt-Kurki, 119-125. 21 Betty Ferrell, “Ethical Perspectives on Pain and Suffering,” Pain Management Nursing 6(2005):83-90. 22 William Hampes, “Relation Between Humor and Empathic Concern,” Psychological Reports 88 (2001): 241-244. 23 Harvey Chochinov, Thomas Hack, Susan McClement, Linda Kristjanson and Mike Harlos, “Dignity in the Terminally Ill: a Developing Empirical Model,” Social Science & Medicine 54 (2002): 433-443. 24 Felicia Cohn, “Existential Medicine: Martin Buber and PhysicianPatient Relationships,” Journal of Continuing Education in the Health Professions 21(2001):170-182.

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___________________________________________________________ 25

Diane Gustafson, “Embodied Knowledge or Disembodied Knowing?” Canadian Nurse 99 (2003): 8-9. 26 Dennis Waskul and Pamela van der Riet. “The Abject Embodiment of Cancer Patients: Dignity, Selfhood, and the Grotesque Body.” Symbolic Interaction 25 (2002): 487-513. 27 Ibid 28 Kaye Herth, “Contributions of Humor as Perceived by the Terminally Ill.” American Journal of Hospice Care 7 (1990): 36-40. 29 Astedt-Kurki, 119-125. 30 Chochinov, 433-443. 31 Henman, 83-94. 32 Allen Klein, The Courage to Laugh: Humor, Hope, and Healing in the Face of Death and Dying. New York: Penguin Putnam, 1998. 33 Herth, 36-40. 34 Allen Thornton and Alan White, “A Heideggerian Investigation into the Lived Experience of Humour by Nurses in an Intensive Care Unit.” Intensive and Critical Care Nursing 15 (1999): 266-278. 35 Marianne Wallis, “Responding to Suffering: The Experience of Professional Nurse Caring in the Coronary Care Unit.” International Journal for Human Caring 2 (1998): 35-44. 36 Joanne Major, Critical Care Nurses’ Use of Humor. Unpublished Master’s Thesis, University of Manitoba, Winnipeg, Canada (1998). 37 Gustafson, 8-9. 38 Marlaine Smith, “Caring and the Science of Unitary Human Beings.” Advances in Nursing Science 21(1999): 14-28.

Author Ruth Anne Kinsman Dean, RN, PhD, Faculty of Nursing, University of Manitoba, Winnipeg, MB. Canada R3T 2N2 This research was supported by a Doctoral Fellowship from the Social Sciences and Humanities Research Council of Canada and a Research Grant from Riverview Health Centre in Winnipeg, MB.

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Index A absenteeism, 167, 184 acceptance, 79, 196 acknowledgement, 52 aetiology, 2, 51 aged care facilities, 165, 167 agitation, 63, 80 alienation, 47, 140 anticipation, 116 anxiety, 1, 31, 46, 48, 50, 52, 61, 62, 65, 73, 78, 79, 80, 81, 82, 84, 93, 98, 103, 104, 106, 107, 117, 118, 120, 121, 123, 127, 129, 130, 131, 166, 168, 176, 191, 196, 203 artistic viewpoint, 138 asylum seekers, 123, 124, 125, 127, 130, 132, 133 attrition, employee, 184, 188 authenticity, 196, 197 Avoidant Paruresis, 103, 106, 107, 119

B Bashful Bladder, 103 Beck depression test, 82, 88 biological approach, 35 body politic, 4 boundaries, 47, 137, 140, 141, 142, 143, 145 burnout, 23, 175, 177, 178, 184, 185, 186, 187, 188

C classification, 2, 48, 105, 108 clinical ethnography, 191 Cliniclowns, 137-164 Clown Care Unit, 137, 165 clowns in hospitals, 175 clown-doctors, 175, 176, 177, 178, 179, 180, 187 nurse-clowns, 150

coherence, 32 collective, 4, 6, 8, 34, 73 conciousness, 4 depression, 1, 3, 4, 5, 6, 7, 8, 9 insight, 1 memory, 4, 31 mind, 4 unconscious, 4 collective action, 8 collective anxiety neurosis, 6 collective mental state, 7, 8 collective paranoia, 6 comfort, 105, 125, 129, 132, 172, 178, 187, 199, 202 communication, 34, 51, 54, 160, 166, 168, 169, 191, 192, 193, 195, 199, 200 communicative memory, 31 compassion, 64, 195, 200 concept, 4, 33, 34, 36, 43, 44, 48, 52, 67, 79, 80, 81, 82, 83, 88, 103, 109, 111, 113, 116, 138, 141, 167, 202, 204 concepts, 35, 36, 72, 103, 108, 109, 110, 111, 161 connection, 65, 113, 149, 157, 161, 167, 176, 194, 195, 197 consciousness, 107, 109, 193 construction, 36, 107, 116, 150, 151, 156, 158, 159, 161 constructs, 47, 103, 108, 109, 110, 113, 115 consumer society, 53 consumption, 72 contagion theory, 6 coping with, 186 corruption, 67, 130 cost of, 167 counselling, 54, 118, 123, 126, 127, 128, 131, 187 culture-bound syndrome, 63

D death, 2, 3, 5, 13, 127, 141, 187, 191, 197, 198, 199, 202, 203

Index

230

___________________________________________________________ depression, 1, 2, 3, 4, 5, 6, 7, 8, 14, 23, 38, 43, 46, 47, 48, 50, 51, 52, 55, 61, 62, 77, 79, 80, 81, 82, 83, 84, 88, 93, 103, 123, 129, 130, 131, 133, 166, 167, 168, 193 endogenous, 2 reactive, 2 treatment, 14 despondency, 1, 4 detention centres, 123, 131, 133 development, 1, 5, 6, 54, 70, 78, 84, 119, 126, 144, 150, 159, 162 dignity, 137, 197, 204 distress, 23, 26, 47, 50, 51, 54, 63, 68, 80, 105, 106, 113, 114, 180, 185, 194

E educating, 149 elderly, 138, 165, 176, 197, 202 embodied knowledge, 196, 203 emotional, 2, 14, 32, 35, 36, 43, 44, 45, 46, 47, 48, 49, 51, 53, 54, 55, 61, 63, 64, 67, 69, 71, 73, 78, 104, 113, 115, 116, 125, 130, 149, 156, 166, 168, 177, 181, 185, 191, 192, 194, 201 exchange, 46, 50 intelligence, 195 interaction, 46 support, 15, 25 emotions, 6, 32, 36, 43, 44, 45, 46, 47, 48, 50, 52, 54, 69, 142, 158, 160, 195 empathy, 195 empowerment, 93 environment, 23, 50, 79, 80, 93, 94, 95, 97, 98, 101, 103, 110, 111, 115, 116, 126, 128, 131, 137, 139, 140, 141, 143, 149, 151, 152, 156, 160, 161, 162, 163, 168, 169, 175, 184 esteem, 53, 107 evaluation, 160, 163 exchange, 120, 147, 150, 161 excursions, 72, 77, 78, 130 exercise, 70, 77, 78, 80, 81, 82, 83, 84, 85, 88, 128, 192

expectation, 25, 26, 78, 103, 143, 156, 158 expertological regime, 139, 140, 141 expressing regard, 191

F family, 14, 25, 26, 39, 53, 61, 62, 64, 66, 67, 69, 78, 79, 96, 97, 99, 104, 124, 126, 128, 130, 132, 133, 137, 139, 140, 194, 196, 199, 203 family life, 14 fear, 6, 7, 9, 63, 65, 66, 78, 105, 106, 107, 113, 118, 120, 131, 187, 202 female sex workers, 93, 100 folk histories, 31 Fools for Health, 164, 165, 175, 176, 177, 178, 180, 185, 187 forgiveness, 199

G generalized, 78 geriatric patients, 138 group mind, 4 group unanimity, 4

H happiness, 46, 48, 53, 54, 81, 85, 192 harm, 119, 120, 127, 197 healing, 1, 80, 82, 144, 149, 168, 191, 192, 193, 195, 196, 199, 200, 203, 204 health, 4, 6, 13, 14, 15, 16, 20, 21, 22, 23, 25, 26, 43, 44, 45, 46, 48, 50, 52, 61, 62, 63, 64, 69, 70, 72, 73, 77, 80, 81, 82, 93, 94, 95, 100, 101, 104, 117, 120, 123, 126, 128, 131, 132, 133, 139, 146, 149, 151, 161, 162, 163, 165, 166, 167, 168, 169, 172, 175, 176, 185, 191, 192, 204 holistic approach, 140

Index

231

___________________________________________________________ hopelessness, 9, 80, 104 hospitals, 43, 64, 138, 145, 146, 149, 158, 161, 165, 166, 175, 176, 183 human quality, 149 humiliation, 94, 103, 106, 117, 197, 198 humour, 6, 8, 33, 35, 36, 38, 144, 149, 159, 160, 162, 165, 166, 167, 168, 169, 172, 175, 176, 186, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204

I identification, 103, 111, 112, 114, 142, 198 identity, 33, 34, 36, 38, 39, 53, 54, 126, 145, 169, 196 illness, 1, 2, 4, 5, 24, 44, 46, 47, 49, 50, 51, 52, 53, 63, 67, 70, 73, 104, 129, 137, 140, 145, 149, 152, 163, 175, 177, 178, 183, 187, 191, 192, 193, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204 implications, 73, 103, 116, 144 improvisation, 143, 150, 183 inadequacy, 1, 4, 78 individual, 1, 2, 3, 5, 6, 16, 31, 33, 34, 44, 45, 46, 47, 48, 52, 53, 54, 55, 69, 71, 73, 77, 80, 88, 103, 106, 107, 108, 109, 110, 113, 114, 115, 117, 118, 119, 146, 152, 159, 160, 175, 178, 179, 185, 187, 196 individual self, 5 individualisation, 44 insight, 2, 61, 133, 138, 187 integration, 119, 192, 200 interaction, 45, 46, 49, 51, 78, 80, 126, 151, 166, 172, 177, 180, 186, 187, 192 intrapersonal approach, 36 intuition, 6, 138, 181, 182, 191, 203 isolation, 15, 67, 106, 117, 125, 127, 130, 140, 143, 144, 151, 181

J job satisfaction, 13, 15, 16, 19, 21, 22, 24, 26

L lack of vitality, 1, 4 laughter, 31, 36, 144, 149, 159, 160, 163, 165, 166, 168, 169, 172, 186, 191, 192, 200 LaughterBoss, 165, 167, 168, 169 leadership, 1, 6, 7, 8, 9 learned helplessness, 2, 5 learning, 82, 108, 118, 159, 164, 172 life satisfaction, 16, 18, 23, 25, 81 lifestyle, 5, 46, 73, 152 loss of sense of coherence, 5

M marital status, 20, 21, 22 meaning, 1, 5, 38, 39, 52, 53, 63, 77, 138, 152, 153, 162, 202 meaningfulness, 23 medical colonisation, 48 medical students, 13, 14, 149, 162, 163 medicalization, 43, 44, 45, 47, 48, 50, 51, 52, 53, 54 melancholia, 2 memory, 3, 31, 32, 33, 34, 39, 83, 111, 113, 158, 160, 200 mental health, 14 mind, 5, 33, 46, 73, 105, 106, 108, 109, 110, 113, 114, 117, 119, 120, 166, 179, 183, 200 Mood Disorders, 2 morale, 165, 167, 168, 172 morbidity, 14, 23, 167

N negative life events, 36 nervios, 61, 63 causes of, 61, 63, 70

Index

232

___________________________________________________________

O Occupational Stress Indicator, 16 orientation, 103, 114, 115

P palliative care, 166, 176, 191, 192, 195, 196, 198, 199, 204 Patch Adams, 137, 165 peer education, 93 perception, 79, 103, 109, 110, 112, 113, 114, 119, 150, 156, 158, 159, 186, 191 performance anxiety, 104, 118, 120, 121, 183, 187 personal control, 16, 18, 23, 25 perspective taking, 23 pessimism, 1, 4, 78 phobia, 103, 105, 106, 107, 114, 116, 118, 120, 121 phobic state, 107 physicians, 14, 196, 202 consultants, 13, 14, 15, 16, 19, 20, 22, 23, 24 general practitioners, 14, 44, 47 political end, 123 political pressure, 61 positive affect, 16, 18, 23, 25, 192 positive consideration, 79 positive diversion, 168 preserving dignity, 191, 198 pressure, 20, 26, 50, 62, 63, 69, 130, 142, 165, 166, 167 sources of, 13, 15, 16, 19, 22, 24 primary, 48, 105, 118, 119, 139 psychiatry, 44, 47 psychological distress, 50 psychological well-being, 3, 13, 15, 16, 18, 20, 22, 25 psychotherapy, 54, 70, 80, 128

Q quality of life, 64, 81, 100, 117, 118, 144, 167, 168, 176

R rapport, 194, 195 real world model, 103 receptivity, 197, 198, 203 reciprocity, 194, 195, 196 reconciliation, 199 refugee, 62, 123, 125, 129, 131 rehabilitation, 175, 176, 177 relationship, 5, 15, 19, 20, 24, 36, 45, 47, 50, 54, 78, 81, 83, 109, 142, 149, 152, 153, 156, 157, 158, 160, 161, 162, 163, 164, 187, 192, 194, 195, 196, 197, 198, 199, 204 representations, 31, 45, 108 reprieve, 200 research, 4, 6, 32, 36, 45, 48, 61, 62, 63, 70, 72, 73, 80, 81, 82, 94, 121, 138, 144, 146, 149, 150, 152, 159, 161, 169, 175, 177, 178, 179, 185, 187, 191, 192, 195, 204, 206 respect, 64, 79, 100, 130, 158, 180, 193, 195, 204 respite, 201 ridicule, 103, 117, 119, 160, 162 Rote Nasen, 138

S sadness, 1, 4, 47, 180 schemata, 109 script, 109, 111 secondary, 118, 120 self, 16, 34, 36, 37, 47, 52, 53, 54, 72, 79, 80, 81, 82, 83, 95, 107, 112, 119, 120, 123, 127, 128, 158, 159, 163, 169, 183, 186, 191, 192, 193, 196, 200 concept, 77, 87, 88 esteem, 3, 16, 18, 23, 25, 26, 79, 100, 178 harm, 126, 127, 128, 129 insight, 6 sensibilities, 191, 193, 194, 200 Shy Pee 101 social, 5, 6, 25, 31, 32, 33, 36, 38, 43, 44, 45, 46, 47, 48, 49, 50, 51,

Index

233

___________________________________________________________ 52, 53, 54, 55, 63, 64, 65, 66, 68, 69, 70, 71, 72, 78, 80, 83, 94, 95, 100, 103, 104, 105, 106, 107, 108, 109, 111, 116, 117, 118, 119, 123, 126, 130, 131, 132, 133, 138, 139, 140, 146, 151, 159, 161, 176, 179, 186, 193 construction, 31 consumption, 53 identity, 31, 34, 37, 38, 39 learning, 1, 6, 108 memory, 33, 34, 83 representations, 31, 34, 39 support, 16, 18, 38, 101, 187 social support, 15 social anxiety disorder, 117, 118 social engineering, 7 social learning, 108 social life, 14 social memory, 83 sociogenesis, 6 sources of, 194 specific, 104, 105, 106 spontaneity, 196 stigmatization, 93, 100 stress, 2, 13, 14, 15, 16, 20, 23, 24, 25, 26, 31, 34, 39, 52, 61, 62, 63, 65, 66, 67, 71, 72, 73, 78, 84, 88, 129, 130, 131, 133, 149, 165, 166, 167, 168, 177, 178, 179, 180, 182, 183, 184, 185, 186, 187, 188, 193 perceived level of stress, 36 stress relief, 72 stressors, 14, 25, 70, 73, 177, 178, 183, 185, 186, 187 subjective reality, 103, 110, 113, 116 support, 24, 48, 53, 54, 64, 66, 80, 82, 94, 97, 98, 117, 120, 123, 130, 131, 132, 138, 146, 147, 158, 161, 168, 169, 178, 179, 180, 184, 187, 188

T tension, 5, 16, 18, 23, 26, 37, 39, 66, 105, 119, 179, 197 Theodora Foundation, 137,138, 165 therapeutic humour, 166 tolerance, 15, 47, 64 toxicity, 1, 8 training, 15, 80, 107, 111, 112, 149, 150, 152, 153, 157, 158, 159, 160, 162, 165, 167, 168, 169, 180, 186, 187 trauma, 1, 3, 113, 123, 127, 128, 129, 130, 132 treatment, 1, 44, 48, 50, 51, 64, 70, 77, 80, 81, 82, 83, 84, 85, 86, 88, 103, 104, 117, 118, 125, 131, 146, 149, 152, 161, 175, 193 trickster, 141, 144

U unconscious, 8, 109, 112, 113, 114, 116 understanding, 6, 33, 53, 54, 79, 95, 104, 108, 112, 115, 116, 117, 121, 140, 149, 168, 195, 198, 199

V victimization, 93

W webcam clowning, 138 well-being, 13, 14, 15, 16, 18, 20, 21, 22, 23, 24, 25, 26, 46, 61, 64, 73, 77, 119, 137, 139, 144, 145, 187 wellness, 16, 18, 23, 25, 166 wounded healers, 14