In the federal government report, Healthy People 2010, which was written in 2000 and speculated on the upcoming problems facing the population, one of the objectives identified as a barrier to effective healthcare was the problem of health literacy. Health literacy goes well beyond the specific problem of an inability to read. The report defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Making appropriate health decisions is a huge task made up of thousands of tiny ones. Scheduling and keeping appointments, knowing medications and dosages, understanding complications, consenting to procedures, and reading health information are all critical components.

Healthy People 2010 reports that as much as 30% of the United States population is either health illiterate or only has a “basic” literacy, meaning that they can only comprehend the most remedial tasks. Most people who are health illiterate either have a job or are retired workers, meaning they are otherwise functional within society. The problem is especially worrisome within the elderly population, where two thirds of adults over age 60 have inadequate or marginal literacy skills, and 81% of patients age 60 and older at a public hospital could not read or understand basic materials such as prescription labels. Other groups with high levels of health illiteracy include immigrant populations, minorities, and patients with lower incomes. About half of Medicare/Medicaid patients read below the 5th-grade level.

According to the AMA, having poor health literacy is “a stronger predictor of a person’s health than age, income, employment status, education level, and race.” Patients with inadequate literacy tend to suffer from more complications from medications due to errors in dose and timing. Medical complications are also more common because patients are less likely to follow-up with conditions that require it, and in general are less compliant with physician instructions. Without clear and accurate language to describe their symptoms, patients with less health literacy are also more difficult to evaluate and diagnose, leading to longer times until appropriate treatment is initiated. The cumulative effect is that poor health literacy costs the United States over 100 billion dollars every year in extra healthcare and lost productivity.

Ultimately the issue of health literacy needs to be addressed on a national level with a well-funded initiative for patient education and awareness. However, anything professionals can do to facilitate better communication is of the utmost importance for the well-being of our patients. Everybody in the healthcare profession needs to recognize the possibility that patients may not be understanding what is expected of them. Simple changes like providing a plainly written care plan for the patient to take home after every visit can help to avoid potential errors. After an encounter, rather than asking patients if they have any questions, consider instead to ask if there is anything you can explain more clearly. We may not be able to change our patients’ behavior overnight, but we can start by changing our own.

Domestic Violence expert John Hamel, LCSW recently addressed this, with abundant research citations, for a book chapter. I will provide, with his permission, his annotations. But why? First, derogatory stereotypes are bad in principle. Second, the stereotypes cause people to downplay or ignore domestic violence and related behaviors by women. Third, funding for shelters and other services for men who are victims of domestic violence is affected. Fourth, men may end up as victims of the justice system when it turns against them because of the stereotypes.

Consider these two examples:

A volunteer who presents about male victims was presenting to a police department. She had 200 law enforcement personnel present. At the end, she got a police officer to volunteer a call to a shelter, posing as a male victim. He called a hotline for a battered womens program and asked about services for men, explaining that he was experiencing violence at the hands of a female. The hotline worker said, “You should be in jail.” The officer restated that he needed help because his wife was violent. The hotline worker hung up on him.

In a recent article in the San Diego Metro Weekly domestic violence was mentioned in the context of the California Supreme Court ruling in favor of gay marriage, regarding gay divorce. It says,

And, if any violence has preceded the divorce discussions and say… the local gendarmerie is called in, our boys are subject to domestic violence laws, which are stickier by far than if they were single and decided to box each other on the ears.

This not only assumes there is no violence in lesbian relationships, and there certainly is, I’ve seen it, but it also diminishes the seriousness of it by referring to it as boxing the ears.

Hamel’s Review of Research

Now here is a taste of Hamel’s review of the data. Thank you, John!

Straus et al. (1980); Straus & Gelles (1990). Both National Family Violence Surveys, with a combined sample of more than 8,000 respondents, reported comparable gender rates for not only physical assaults, but verbal abuse as well.

Rouse, Breen and Howell (1988). This survey of 130 dating and 130 married students found that women are more likely than men to engage in isolation behaviors, such as “monitors time,” “discourages same-sex friends” and “discourages opposite sex friends.”

Stets (1991). The male and female respondents in this study of dating students reported equivalent rates of controlling behaviors (e.g., “I keep my partner in line,” “I am successful in imposing my will onto my partner”), as well as psychological abuse (e.g., “Said mean things,” “Degraded him/her”).

Kasian & Painter (1992). The authors surveyed a large sample (1,625) university students. Male respondents reported higher rates of received abuse, as measured by a modified version of the Psychological Maltreatment of Women Inventory, for control, jealousy/isolation, verbal abuse and withdrawal of affection. There were no gender differences in rates of received emotional abuse (“diminishment of self-esteem”).

Feder and Henning (2005). In this study of 317 couples dually arrested for IPV (interpersonal violence), most of them African-American, criminal justice data revealed no differences between the partners in injuries inflicted or weapons use. Interview data revealed no differences in physical assault; women were more likely to use a weapon, but to suffer slightly higher rates of injuries (19.6% vs. 15.0%). There were no gender differences in overall psychological abuse or coercive control tactics.

Stacey, Hazelwood & Shupe (1994). Higher rates of victimization than perpetration were reported by the male subjects in this Texas study of men in batterer treatment on four of the thirteen items from the CSR Abuse Index: “deny rights to privacy,” “deny access to family,” “withdraw emotions to punish,” and “withhold sex to punish.” Although the men reported lower rates of victimization than females on the other items, the differences were usually not large (e.g., “deny freedom of activities” was cited by 71% of men and 72% of women; “deny access to friends” was cited by 57% of men and 63% of women, and “censor phone calls” was reported by 53% of men and 60% of women.) One would have expected much larger differences from this population, considering that the men had been arrested and deemed “batterers,” while their female partners were deemed the “victims.”

Tjaden & Thoennes (2000). The National Violence Against Women Survey (NVAWS), drawing on a sample of 16,000 men and women, reported that 0.2% of men are stalked each year by a current or former intimate, and 0.5% of women, a ratio of 2.5 women for each man victimized. In addition, .038% of the men reported to having been raped the previous year. Five times as many women (0.2%) said that this had happened to them.

Spitzberg & Rhea (1999). The authors examined a variety of stalking subtypes, collectively known as obsessive relational intrusion (ORI). Results from their sample of college students in Texas revealed a 54% rate of male-perpetrated ORI’s, versus 46% for females.

Langhinrichsen-Rohling, Palarea, Cohen & Rohling (2000). In this college survey, respondents were asked to report on their own ORI behavior, as well as incidents of victimization. There were no overall gender differences in stalking rates. However, men made more unwanted visits to homes and apartments, whereas women left the greater share of unwanted phone messages. Women were also four times as likely to report having been physically threatened.

Meloy & Boyd (2003). The authors reported on 82 female cases from mental health clinics and some who came to the attention of law enforcement. The women were similar to male stalkers in having a history of failed intimate relationships and having cluster “B” DSM IV personality disorders (not antisocial). They were also similar in that 50% — 75% threatened and 50% — 55% assaulted their victim. But they were different in that they more often carried out threats and caused property damage.

Busby & Compton (1997). A large survey of 3,034 engaged couples reported that 6.1% men and 13.0% women had been sexually pressured by their partner.

O’Sullivan et al. (1998). In this survey of 433 dating university students, 18.5% of the men and 42.5% of women reported to having been sexually coerced by their partner.

Muehlenhard & Cook (1988). This college study revealed that men more often than women engaged in unwanted sexual intercourse, at rates of 63% versus 46%. Being taken advantage of when intoxicated was reported by 30.8% of the men, and 21.0% of the women. Among the men, 13.4% had been verbally coerced, and 11.5% of the women said that this had happened to them. The rates were 5.7% for men subjected to nonviolent coercion (e.g., blocking the door, holding the person down), compared with 5.4% for the women. Coercion involving physical assaults was experienced by 1.4% of the men and 2.7% of the women.

Waldner-Haugrud & Magruder (1995). The authors asked a dating population about a range of coercive sexual behaviors. In the previous year, the men had an average of 2.26 incidents perpetrated upon them, and the women 2.86. Persistent touching was reported by 51% of males and 70% of females. Men were twice as likely to report blackmail (8.5% versus 4.2%); women reported a higher incidence of manipulative guilt (30.1% versus 22.5%). The women were twice as likely as men to be restrained or detained, and more threatened with physical force (6.9% to 6.0%); but three times more men had weapons used against th em (4.5% versus 1.4%).

Coker, Davis, Arias, Desai, Sanderson, Brandt & Smith (2002). A re-examination of data of 16,000 respondents from the National Violence Against Women Survey found lifetime male victimization rates of 10.5% for experienced verbal abuse and jealousy/possessiveness, and 6.8% for power/control, compared to rates of 5.2% and 6.9% for women.

Riggs, O’Leary & Breslin (1990). Found a strong correlation between having a dominant and aggressive personality and IPV for both men and women.

Cano, Avery-Leaf, Cascardi & O’Leary (1998). Found a significant correlation in high school dating study for boys and girls between the use of jealousy and dominance tactics and physical assaults.

Hines & Saudino (2003). Using the Revised Conflict Tactics Scale, this survey of 481 university students found comparable levels of physical aggression between the genders. Women were found to have engaged in higher levels of psychological aggression, and the two types of abuse tended to co-exist.

Graham-Kevan & Archer (2005). Drawing upon a community sample of university students and faculty in Lancashire, England, the authors found rates of 13% for female intimate terrorists and 9% for male intimate terrorists, based upon the same criteria as used by Michael Johnson (a combination of physical violence, control, and psychological abuse).

Laroche (2005), and Graham-Kevan (2007). Laroche analyzed a massive Canadian study, the 1999 GSS, involving 25,876 respondents. Respondents were asked about their victimization by a current or previous spouse in the past 5 years. In addition to questions on physical assaults, the survey also asked respondents about victimization from the following psychologically abusive and controlling behaviors by their partner, similar to those in the Duluth Power and Control Wheel: “Limits your contact with family or friends,” “puts you down or calls you names to make you feel bad,” “is jealous and doesn’t want you to talk to other men/women,” “harms or threatens to harm someone close to you,” demands to know who you are with and where you are at all times,” “damages or destroys your possessions or property,” and “prevents you from knowing about or having access to the family income, even if you ask.” For the five year period prior to the study, approximately 3% of the surveyed women, and 2% of the men, were counted as victims of severe intimate terrorism (IT) – defined as having experienced severe and frequent physical violence and high levels of psychological abuse and control, and who would fit Ehrensaft et al.’s “clinical abuse cases” from injuries sustained, fear expressed, and use of police and other services. Graham-Kevan analyzed the results of the same survey, except that she focused on abuse reported for the past year only, and found very comparable rates of intimate terrorism between the genders. This is a remarkable finding, considering the study’s methodology (akin to the NVAWS in t hat its questionnaire framed IPV in terms of personal safety rather than conflict, thus suppressing male victimization rates) and “the inadequate assessment of controlling behaviors suffered by men” (Laroche, 2005, p. 11).

Felson & Outlaw (2007). An analysis of data originally obtained through the NVAWS with a sample of over 15,000 currently married or formerly married adults found that: (1) women are just as controlling and jealous towards their male partners as other way around; (2) the relationship between use of control/jealousy and physical violence exists equally for both male and female respondents; (3) “Intimate terrorists” can be either male or female. (Controlling/ jealous behaviors defined as: “Prevents you from knowing about or having access to family income even when you ask”; “Prevents you from working outside the home”; “Insists on knowing who you are with at all times”; Insists on changing residences even when you don’t want or need to”; “Tries to limit your contact with family and friends.”) Regarding the extent to which men and women engage in “intimate terrorism,” the authors write: “Both husbands and wives who are controlling are more likely to produce injury and engage in repeated violence. Similar effects are observed for jealousy, although not all are statistically significant. The seriousness of the violence is apparently associated with motive, although the relationship does not depend on gender” (p. 404). It should be pointed out that the National Violence Against Women Survey was designed, conducted and analyzed by feminist researchers, who sought to prove that violence against female intimate partners is much more serious than violence against male intimate partners.

Straus (2006). 7.6% of the male respondents and 10.6% of the female respondents interviewed in the International Dating Violence Survey (sample of 13,601 university students in 32 countries) reported having perpetrated severe assaults, and both partners were found to be violent in 68.6% of the cases. Based on 9 items related to dominance on the PRP (e.g., “my partner needs to remember that I am in charge”), the survey found overall dominance scores to be equal across gender, although higher dominance scores were found for women in 24 of 32 countries. It was also found that dominance by either partner increases the probability of severe violence, and that dominance by females increases risk of severe female-only or mutual IPV more than does male dominance.

I’ve spent a great deal of time thinking about this subject. Increasingly so in the past several years because I have particular need in my personal life to understand this trait so that I might better manage my own feelings of disappointment related to this subject where my son’s constant battle with chronic major depressive disorder is concerned. I aspire for a kind of closure that would facilitate my utilizing that gained energy toward increased focus in supporting my son’s health, as well as to the assistance of other’s goals of enhanced wellness where addiction and mental health related issues are concerned. As a direct result of my experiences related to my unavoidable involvement and through investments in this edification, I accept that some people, for varying reasons, have a lesser capacity to act in service in even the simplest forms of support and encouragement in relation to the compassion they experience. I would go one step further and communicate that this kind of diminished capacity is especially prevalent with regard to the subject of compassion as it concerns addiction and depressive mental illnesses.

There are slightly varying definitions for the word compassion; differentiating from empathy, sympathy, and pity can be a bit tedious as they are often used in description of one another. However, it is defined in the GoodWiki pages from the Greater Good Science Center, University of California, Berkeley, as:

… a feeling of sorrow, or concern for another person’s suffering or need accompanied by a subsequent desire to alleviate the suffering.

Note that it doesn’t read:

… a feeling of sorrow or concern for another person’s suffering or need that results in a desire, followed by an action, to alleviate suffering.

There is documented research explaining why the latter, enhanced definition would be inaccurate. I think the explanation of this holds inherent truths, specifically as it relates to societal stigmas.

It appears, based on researched evidence, that benevolence is directly impacted by the way individuals process their own response to feeling compassion. The resulting self-regulation of that emotion determines whether the individual will act in an altruistic, benevolent manner in connection to another’s recognized need, or that a person may instead process their initial feeling of emotional response in a manner that produces subsequent personal distress. A personal distress response will not necessarily result in an action-oriented behavior aimed at easing the pain of someone else. The research supports that sympathy motivates people to act benevolently, while personal distress can cause an “egoistic” response. There are even polar opposite physiological responses to the individualized processing of sympathy and personal distress. Studies show that sympathy can produce a decrease in heart rate, while personal distress, on the other hand, can initiate, you guessed it, an increase in heart rate.

Okay, so there it is. The terms “personal distress” and “egoistic” explain a great deal, at least to my understanding. Basically, what I gleaned from my reading is that some people act as a result of their feelings of compassion in a way that they believe will serve the need of someone else. Others act in a way that would serve to assist in the avoidance of further investment outside of their initial emotional response. The study supported that this is due to a self-perceived anticipation of encountering “stress,” thus “personal distress,” associated with that investment.

I have a personal need to better understand the emotion of empathy. This subject of compassionate response as it relates to addiction and depressive illness helps serve my goal in assembling a reasonable, thoughtfully-woven perspective as to why I witness a rampant lack of action-oriented compassion in relation to those suffering the isolation they often experience in coping with the effects of the disease. Frankly, the perspective I have been forming over the years is affected, too, by my inexpressible disdain for the many uninformed commentaries and downright hateful, critical judgments that occur frequently in our society with regard to the clinical and social realities of addiction and depressive mental illness. There exists a huge amount of conscious and unconscious perpetuation of stigmatic energy associated with the disease. We ALL witness the demoralizing result, and collectively we are all allowing it to continue. The presence of this stigma assists to impede advancements in treatments and cures. I’m unaware of another disease whose proliferation as well as successful treatment is dependent upon pro-socially motivated emotional response, or is as innately rooted in how we act or don’t act in terms of compassion.

One result of this stigma is that it causes a diminished capacity in recognizing the disease as one of physiological origin. It’s a complex issue, as we tend to be wired to judge the symptomatology of the disease as character-related. Subsequently, we often distance ourselves when we perceive that another’s challenges are a result of willful “bad behavior,” rather than understanding that the behavior is one resulting from the presence of a physiological, or psychological impairment. In contrast, when we witness someone struggling with what we perceive as a physical ailment, we are much more likely to respond with an encouraging, compassion-related action. As well, this compassion-related action is also more likely to occur in response to the perceived emotional suffering of another when we see it as result of physical injury and disease. Because we are not as apt to recognize the behavioral impairment and subsequent choices relating to that behavior as stemming from physiological components occurring from disruptions in normal brain functions, we don’t respond properly in terms of need, treatment and cure. Even when the behavioral symptomatology is recognized as having physiological origin, apathy still occurs. The possibility of self-perceived personal distress is a contributing factor in this apathetic response. The bottom line is that we fall unwitting victim and perpetrator, of sorts, in the amplification of a rebounding, vicious cycle of disease, which impacts the patient, the family, and ultimately the community. It is a disease of phenomenal scale as it relates to family dynamic and its reverberations in societal context.

This leads me to what I perceive is a logical conclusion. In order to restrain and thus improve the far-reaching, devastating effects of addiction and depressive mental illness, there is requirement, first and foremost, in reversing the stigma associated. It needs to happen now. The cure is dependent on this focus. Every single person is impacted by the presence of the symptomatology of this disease. Do that math. It should not require calculative tools to ascertain that we are witnessing an ever-increasing need for counter actions that will reduce the unparalleled, prolific resonance associated with addiction and depressive mental illness stigma.

I have invested in supporting my child in his battle with the life-threatening symptomatology associated with chronic Major Depressive Disorder. We had to get a grip, or we were going to lose him. Admittedly, we have not done everything right. It’s impossible. It’s exceedingly difficult to always know exactly what to do in regard to the symptomatology. But disconnect?… NOT AN OPTION. So, we persevere, everyday, inspired through responsible, dedicated love. It’s hard to hang there, at times. The symptomatology sucks up all manner of resources. I’ve referred to the investment in my son’s illness as like being, at times, “tied to a tornado,” with respect to the illness’s unpredictability. Its power to devastate everything in its path is increased if it is not responsibly, compassionately treated. I wouldn’t dream of presuming to understand anyone else’s parameters of engagement. Every case is unique. I’m just trying to be clear that I would rather be tied to a tornado than freed of that connection through his departure from this earth as a result of his illness.

A great deal of the challenge I personally experience in connection with the disease is a direct result of the associated stigma. I have developed an inexpressible disdain for the many uninformed comments and downright hateful, counterproductive, critical judgments that I am exposed to in our society in regard to it. You witness them, too. But, I have acquired an improved understanding as to why some of us don’t take our feelings of compassion to the next step of responsible action — action of encouragement and service to another person in need. I get it, alright. But still, I experience disappointments related to the fact that I, and many others, shouldn’t have a need to work so hard to understand this counter-productive response to the disease in the first place. That energy would better serve to support those struggling to cope with the disease.

Something else I am forced to recognize? All that logical assertion serves little good. All the cognitive conclusions in the world will never be adequate in facilitating a filling-in of the shameful gap created by rampant, societal disregard. No… That gap isn’t going to fill itself, making itself a pretty, little blossoming cherry tree-lined, cobblestone path to the land of, “Nobody Has Drug Addiction Tendencies or Mental Health Issues, USA.” Nice place, I suppose, if you can get there. Since I’ve been trained to expect the unexpected due to my experiences with my son’s illness and have also learned to be responsible for creating my own sense of hope from what is, at times, seemingly, hopeless, I’ll keep a suitcase packed, just in case. I’d be thankful to relocate. But in absence of that reality, I believe the bridging of disease, to treatment and cure, specifically related to this human condition, begins with an action-related, compassion-born foundation. We are all in this quest together, because together, we have created much of the need.

We are not solitary creatures. We exist in a family, community, society, and global scope.We need each other. We all intensely desire a sense of acceptance and inclusion on some level. Existence in this spirit promotes wellness, so it makes perfect sense that addiction and mental health related stigmas would serve in opposition of health.

We need to do better in honoring the state of humanity as it relates to addiction and depressive illness. It’s not enough just to feel compassion or empathy. Dedicated, heart-driven, solicitous, actions serve prevention, serve treatment, and serve cure.

References

Batson, C.D., Fultz, J., Schoenrade, P.A. (1987). Distress and Empathy: Two Qualitatively Distinct Vicarious Emotions with Different Motivational Consequences. Journal of Personality, 55(1), 19-39. DOI: 10.1111/j.1467-6494.1987.tb00426.x

Eisenberg, N. (2002). Empathy-related emotional responses, altruism, and their socialization. In R. J. Davidson & A. Harrington (Eds.), Visions of compassion: Western scientists and Tibetan Buddhists examine human nature (pp. 131-164). London: Oxford University Press.

Zhou, Q., Valiente, C., Eisenberg, N. (2003). Empathy and its measurement. In S. J. Lopez and C. R. Snyder (Eds.), Positive psychological assessment: A handbook of models and measures (pp. 269-284). Washington, DC, US: American Psychological Association.

However, as I have closely followed the sexual dimorphism debate over the years, I am of the opinion that although there is irrefutable scientific evidence that there are important differences in the way male and human brains function, they are not significant enough to justify any role stereotyping in humans on a purely biological basis. Women can become Sumo wrestlers if they wanted to and they do these days; in fact Japan held its first-ever official women’s Sumo wrestling championship in 1997 breaking away with the age-old tradition of keeping women away from the arena, even as spectators. Women in the 20th century have been fairly successful as “father role models,” despite significant opposition to the idea from orthodox quarters.

Recent behavioral research has focussed on the gay male brain, and one such recent study (2) from the Queen Mary Hospital, University of London has reported that when it comes to spatial navigational abilities, gay men’s performance tend to equal that of women, which under laboratory conditions, is worse compared to straight men. In the computer-simulation study carried out on 140 volunteers, gay men, straight women and lesbians shared the same weaknesses when it came to tasks that required spatial navigational abilities. I can accept that as a possible explanation why there are so few women who aspire to be fighter pilots, while arguing of course that current combat aviation technology is still not quite as gender-neutral as one can hope for. But in the above case, the reaction of the British press all across the UK to this research finding was simply hilarious.

For example The Telegraph, a national daily ran its story “Women and gay men are worst drivers,” without justifying their assertion. Worse, an accompanying picture was captioned, “Be afraid: gay men or women could be behind the wheel of any car.” Despite the fact that in Britain women are universally acknowledged as safer drivers, and pay less insurance than men (indeed in my household, both our cars are insured in my wife’s name, quite legally of course). Here is a classic demonstration of the pitfalls of illogical stereotyping through misinterpretation of research findings — life skills in modern human society are too complex to be evaluated on the basis of laboratory tests of simple behavioral tests alone. Dr. Rahman, the senior author agrees that “the headlines splashed across the British press about driving were completely taken out of context.”

Behavioral psychology is valuable in numerous aspects, but we must be cautious about jumping to conclusions. And I have always acknowledged that at least in my family, my wife is the better driver.

References

1. Why Men Don’t Listen And Women Can’t Read Maps: How We’re Different and What To Do About It: How We’re Different and What to Do About It. Barbara and Allan Pease. Orion. March 2001.

2. Rahman, Q., Koerting, J. (2007). Sexual orientation-related differences in allocentric spatial memory tasks. Hippocampus, 18(1), 55-63. DOI: 10.1002/hipo.20375

The topic of this entry is remediation of brain processes. The art and science of healing your brain is in its infancy, but there is some very good info out there. What we’re talking about is expediting your recovery.

1. Conditions for recovery. Just in case you forgot, you have to give your brain the conditions that it needs in order to heal as efficiently as possible. That means rest, nutrition, not taking too much on in your drive to get back to normal, and having as much peace and support in your life as possible. My first regular work in my recovery was falling back on an art I dearly love, massage therapy. What a working environment for someone recovering their brain. Dim light, people who you make happy, physical exercise, aromatherapy, doing one thing at a time, hour to hour and a half-long conversations with doctors, lawyers, design professionals and biotech scientists of San Diego that helped me perfect my conversational skills. Does it get any better? Oh, and using mostly motor memory skills that I already knew. Generally, motor memory sticks best of all, so people in manual professions may have an easier time getting back to making a living.

2. Practicing and building basic brain processes with brain games. I wish I were deep into this, but I can only tell you that research is starting, repeat, starting to support the use of things like brain games to support recovery. Plenty of elderly people are playing games on the Internet right now in order to maintain their brain function. That’s gotta be even better than watching Jeopardy on TV. I have been using Lumosity.com (not luminosity, it’s lumosity) and have been getting results after about five weeks of use. I’m not getting paid for saying this. Wish I were. I’m getting more ideas and engaging in more forethought, for example. And this is more of a jump in ability than I’m used to seeing in my recovery. The games are designed by neurologists specifically for this kind of purpose. They offer a two week free trial. It tracks your progress with charts, too. As I go about my affairs, I notice that my brain is reaching for the same resources that the games have been training it on, in order to improve my scope of competence in real life.

3. Nutrition and exercise. Whatever your specific needs may be, there are some general guidelines that may be helpful. This is such a big subject, but here are some basics. It seems that creating more brain-derived neurotrophic factor (BDNF) is an important consideration. Exercise and Omega3 fatty acids have been identified as supportive of this. Diets already thought of as healthy appear to be good for your brain. Gee, you’d almost think your brain is part of your body. Wait! It is! Less high glycemic index (sugary or starchy) foods, less animal products, more green and orange vegetables, lower calorie intake, and variety are good principles for most folks. Keep learning about supplements and nutrition. My ADD and supplements page has some related information.

4. Systems. When it comes to organizing your information and calendar, what works for everybody else probably won’t work for you. People in recovery may have to go as far as having an emergency page in their notebook that tells them what to do if they get too confused while they are going somewhere. It might have tips like reminding them to call their key people with the cell phone. Creating systems is a task fraught with potential pitfalls. It’s best to have help putting something together that you can commit to, and making sure you post a note to remind you that it exists and that you shouldn’t create a new one that splits your information into yet another location.

5. Appropriate retreat. I said you should not assume that you belong at a lower level of functioning. You might just be missing splinter skills. But then there is the matter of how MUCH to do. Pulling back from quantity is definitely a good idea. Building up your skill and handling of specific situations is much more important than building volume, at least in the beginning and intermediate levels. Be aware of the signs of stress that tell you to back off. For me, it was sound becoming painful. Yes, hearing sound was painful. I love sound, so this was a strange symptom.

6. Effective sleep and stress reduction. Make sure that psychological trauma, sleep apnea, and other factors are not interfering with your sleep. Stress management training, hypnotic recordings, and eye movement desensitization and reprocessing (EMDR) are example modalities that can prove helpful. This is another huge subject.

7. Busy work. If you aren’t able to take on full responsibility or employment, and you have some time on your hands, come up with tasks related to your profession to do, whether it’s physical or mental. If you’re a white collar professional, keep reading as much as possible about your field. Trouble reading? Get someone to install a text reader, or to discuss the material with you.

8. Social interaction. Without overdoing it, get into conversations about anything and everything. Expand your world. Building up that neural net of yours includes getting up to speed with social cues and interplay, as well as working with ideas on the fly.

Great Related Reading

I Wanted My Brain Back, By Sherri Dalphonse, Washingtonian.com – This is a wonderful article about a woman’s recovery from brain injury. It’s more than just a human interest story, it’s helpful.

More Info

Eat Smart: Foods may affect the brain as well as the body. Science News, 3/4/2006.

Buff and Brainy: exercising the body can benefit the mind. Science News, 2/25/2006.

Failing at things that you used to do? Odds are, there are the missing links in your chains of successful behaviors, such as networking, pulling yourself together in the morning, responding to a creditor, or managing your papers, maybe even in managing your emotions or dealing with a verbal conflict.

Running Into Walls

In my recovery, a recurring surprise was that I would go into a situation that I had not navigated since the injury, and I would not handle it successfully. It was always a complete shock, because I had no sens of being unable to do it. That’s because, like everyone else, I was relying on many splinter skills that function pretty much unconsciously in order to do these things.

At first, I simply retreated, assuming that I was too disabled to function at that level in general. In time, I realized that was not the case. I had a variety of good skills, but they were perforated by missing splinter skills. Of course the emotional instability, fear, shame, and fatigue disguised this at first. As I began to get those things handled, it became pretty obvious that I needed to literally “reinstall” the missing skills.

Take networking, for example. I recall that I met someone who might connect me with a good opportunity down the road. I should follow up. But where’s the number? Well, it’s on their card. Where’s the card? Last I recall, they were handing it to me. In order to fix this problem, I had to go through a rather painful mental process of recreating what, in the past, had been a more or less unconscious behavior: having a place where such things go and a time to input the information. It sounds so SIMPLE. And it was, once I reinstalled the behavior.

So here’s a bit of irony. When you pick up enough of these dropped skills to get your confidence back, some goofball will tell you, “See, you just needed to get your confidence back.” Try not to hurt them too badly.

And moving? It was as though I were a twelve-year-old thrown into an adult responsibility. It went pretty badly. But, prior to that move, I had always known exactly what size truck was needed, how much help was needed, and I always arrived at my destination on schedule! That episode was the first thing that really clued me in on this lost splinter skill issue.

As I expanded the scope of my writing, I found myself rediscovering how to spell words like “phrenetic,” no, “frenetic,” ah, there we go. This was not damage to my ability to spell, it was damage to my memory of how to spell. Once I re-learned the word, I did not forget. That is a very important difference! If you have the ability, but fail, consider the possibility that you must reinstall some missing skills.

This is a lot like amnesia, only it involves forgetting things that you had long ago forgotten you knew! ( No wonder it’s so mysterious. It’s no coincidence that approaches to mental illnesses that involve manual-based training in really basic skills are hitting the spot for a lot of people. Whether they know it or not, some of these clients are not learning new skills, but are reinstalling old ones that had been dropped, just like my moving and contact management skill problems.

Anyone who has dropped to a lower level of functioning should make a major priority out of pinpointing exactly what skills are missing. For example, test yourself before plunging into something you haven’t done since the injury, no matter how confident you feel. This can help prevent you from running into walls, so to speak. And don’t just retreat to an overall lower level of expectation when you fail. It may just be a matter of reinstalling missing skills. Yes, there are injuries that can prevent you from re-learning these skills, but even these may be healing so that you will be able to re-learn the skills down the road. Adjusting to limitations does not mean abandoning hope.

There should be a formalized process for assessing what skills may have been dropped and for training on those skills. If this already exists, please let me know. (Surprise me!)

Yes, I understand that there are other deficits that can undermine your functioning, particularly short-term memory. If your errors are primarily because of not being able to retain or process information, it may be a matter of taking more time. But there are things that help many people expedite their recovery, even though they are having a lot of trouble with brain processes as opposed to skills. Been there, done that. I’ll be writing about that, too.

Amazing Statistic

Per the Brain Injury Association of America: Currently, there are at least 5.3 million Americans living with a disability because of a brain injury and the estimated lifetime costs of brain injury (including direct medical costs and indirect costs such as lost productivity) totaled $60 billion in 2000. Every 23 seconds a traumatic brain injury occurs, and in the next year, an average of 1.4 million Americans will sustain a traumatic brain injury.

This made me think of early scientists trying to understand the paths of the planets in the days before they knew the sun was in the center of the solar system. They observed how the planets tracked back and forth in the night skies, and came up with orbits that the planets might be following around the earth. However, there were irregularities to account for, so they came up with orbits within orbits and they still couldn’t work things out. Once they tried it with the sun in the center, it all made sense.

It’s like this with cognitive problems. Until you put the problem in the center of your analysis, you get to theorize in orbits of anger, of morality, of sabotage, of misbehavior, of unresolved psychological issues, and you go round and round. You don’t know where and when to set limits, what kind of help to get, and when you finally pull in the attorneys, it’s all up for grabs.

To see if cognitive problems might be troubling uncle, I asked a small number of questions. How long has he been like this? Is he hoarding? Is the intellectual content of his speech becoming impoverished and more about reminiscing or ruminating than inquisitive and future-focused? (Well, you word this differently in the course of the conversation, if they aren’t bookish.) Before long, I heard a big sigh of relief, as the niece felt the pieces snick into place. I shared the little solar system metaphor with her, and she said that this would really change the family dynamic, and would help them figure out what to do. I mentioned the kinds of professionals that could help them better understand what kind of neurological issues might be in play with uncle, made a referral for a real assessment, and that was it. I wasn’t practicing therapy, I was just raising questions and making suggestions as to the kind of professionals and processes might best serve them.

Since the family had its own issues that predated the uncle’s challenging behavior, getting things straightened out would require an amalgam of mediation and family therapy, if that isn’t redundant.

This series isn’t just about stigma, and it isn’t just about professional assessment and treatment. It’s about recognizing that brain damage is a very common problem, whether it is from an impact to the head, a small stroke, or any of 297 other known causes of cognitive impairment. We may encounter it in the role of employer, employee, child, parent, friend, or lover. Everyone needs to understand how to respond, and how to prevent the unnecessary dangers and chaos that may come from con artists, sociopathic corporations, wrong-headed clinicians, or misunderstandings within our own families. And, knock on wood, should you ever need follow a path of recovery from brain damage, you should have a map.

Resource

Causes of Cognitive Impairment, from WrongDiagnosis.com – This is where they counted the causes of cognitive impairment. You can, too, and more.

Non-Resource

U.S. Centers for Disease Control (CDC) – I went through endless links on their poorly designed website to get to their advice for patients. It is very short, and includes three pieces of advice for managing your affairs after a brain injury. To save you the “brain damage,” here they are:

• If it’s harder than usual to remember things, write them down.
• If you’re easily distracted, try to do one thing at a time. For example, don’t try to watch TV while fixing dinner.
• Consult with family members or close friends when making important decisions.

Once upon a time, I acted as an advocate for a woman I’ll call Cindy, who was suffering from depression and cognitive difficulties stemming from the depression. The problem had cropped up after a number of traumatic experiences that apparently caused a weak link to snap, bringing out this vulnerability to depression. She assigned a new psychiatrist in the county mental health system. This psychiatrist cut off the stimulant medication that Cindy was taking for ADD.

Consider the timing. Cindy had just begun, as a first generation student, to attend junior college. She was in the middle of her first semester. It was a really big deal for her. What was the rationale on the part of the psychiatrist for stopping her ADD meds? “I don’t believe in stimulant medication.”

My role in this mess was provide some support to Cindy by attending an appeal meeting. The head psychiatrist was present, and was acting kind of agitated. His first order of business was to make sure I wasn’t an attorney. When Cindy fumbled and asked for something that wasn’t exactly kosher, the head psychiatrist let her have it with a booming voice (I mean a really booming voice), making her sound like some kind of criminal for daring to ask for this. The woman changed color, but stayed calm and clarified her intent, since he was putting words in her mouth (the straw man attack, as it’s called).

So not only are cognitive deficits to be ignored, but they are a great opportunity for brutal bigotry. At least for some people, even some who have attained a very high level of education, authority, and licensure. Another name I’m not putting in print, despite the temptation.

They understood that I was about to file a malpractice complaint with the medical board, and they restored her medication (maybe they would have anyway, but why wait and see?) But they never considered cognitive issues, but this turned out to be a key to her recovery. Mitigating for these issues in the mean time could have prevented a lot of distress, financial loss, and chaos in her life.

This is a good point to remind you that for many folks, stimulant medication may provide much-needed support for key cognitive functions necessary to hold things together for people who are struggling with some types of cognitive impairment. Also, a lot of brain injury recovery is about regaining abilities and habits that most of us take for granted. It’s a bit like amnesia, except that it is for mostly unconscious habits that are necessary for success. In Cindy’s recovery, I believe this was a crucial aspect.

By the way, please, don’t go away thinking I live to trash the mental health field. I hope that this will help everyone, in the field or not, to look for ways that they can transcend this dynamic and live a more meaningful life. I also hope that clinicians will realize that they have a responsibility to assess, refer, and treat these issues. By describing it from various angles, I hope that I am making the problem much easier to perceive, so that we can respond. I referred to this part as “In the Clinical Dark Ages” because there is so much progress that must be made just to be at a real starting point when it comes to addressing cognitive functioning in the mental health community.

In an upcoming part, I will talk about what can be done to help patch up cognitive problems or slow down progressive versions. In part four, I will give an example of how a family needed to clue into cognitive problems in a family member that would otherwise have led to additional serious problems.

The other day, I saw a man who was walking unsteadily across an alley with the kind of awkwardness that comes from brain damage. The driver of a big white van was impatient and took off, roaring just inches from this man as he was getting across. That will show him for taking too long to heal his broken nerves.

Years ago, I was kicked to the curb after experiencing a brain injury, with the employer perfectly happy about the prospect that I might be too feeble-minded, at that point, to realize I had rights to medical care and other options. With a little luck, maybe I would just walk away and maybe get permanently lost.

I saw a pretty, young bank teller display anger and irritation as she dispensed with an elderly woman who had become too confused to manage her banking effectively. Maybe with a little luck, the old lady won’t have family members who know where her money is and the bank can just absorb it.

I experienced managed care companies and treatment professionals insisting that people with brain damage are now recovered, even though they can’t keep a job.

I reviewed the alarming statistics on homelessness, and how much of it is caused by cognitive disabilities trampled by society’s cruel contempt for anyone who stumbles. And suicide? We can’t be sure about the numbers, but in light of what I am sharing with you, what do you think?

And I must mention the matter of business models. There are marketing approaches and business models for every demographic. The ones for people who are experiencing cognitive problems are chilling. Consider Publisher’s Clearinghouse mailings that are designed to look like an intimidating bill. Bear in mind that they primarily target the elderly. Consider marketing of a mailing list of elderly people touting how gullible they are. And bear in mind that this was proffered by a large, respectable corporation traded on NASDAQ called InfoUSA. And bear in mind that this list was being sold to known con artists.

Somehow, it seeps into our cultural bones that people with cognitive difficulties deserve what they get, and that it’s pretty funny, too.

One of the greatest leaps a minority can make, is to rid itself of the psychological effects of bigotry. This was one of the reasons that the Supreme Court of the U.S. forced school integration. A minority of people who are deeply ashamed have internalized the stigma emanating from the myths of society. Unless they are able to get a good advocate in their corner, or have enough money to get the right attorney, the combination of shame and difficulty with problem solving can practically paralyze a person, making a person with cognitive problems feel like they are swimming with the piranhas, as various interests carve them up. For those who have a type of difficulty that they can recover from, it often takes so long, that their assets are long gone before they are able to wage an effective self defense.

In part three, I will offer up another clinical example in more detail than the ones in part one. It will show just how all of this can creep into the bones of highly qualified clinicians.

Nonetheless, brain damage is the last true refuge of bigotry in the developed world, as I’ll explain in part two. Let’s start with clinical complacence, since cognitive problems are at the top of my current Top Ten Secrets of the Mental Health Field.

In this series, I’m going to share some stories about brain damage including problems with the treatment community — with clinicians such as psychotherapists and psychiatrists. I hope you get mad, scared, and inspired. In my own experience of recovery, I’ve been through more emotions than I knew I had.

People who appear to be well put together, and who can speak reasonably well may have very serious problems brewing as a result of cognitive problems, but no one they encounter, including mental health professionals, are likely to assess them, educate them, refer them, or do anything else about the problem.

I once chastised a psychiatrist for not dealing with signs of brain injury. He said (I am not making this up, I’m so disturbed by this, I can barely keep from printing his name), “Well, there’s no pill for that.” Is that what you’d say about an illness that doesn’t suffer from the stigma and denial that penetrates even into the world of clinicians for this problem?

Inoperable brain cancer would yield referrals for proper care and preparedness for the inevitable. No pill for that, indeed! But not for cognitive issues that aren’t obvious. Why not a referral for rehabilitative services? Why not a referral for counseling focused on preventing going into a tailspin financially or otherwise? Why not help recognizing what is going on? No, it’s better to ignore the issue entirely, and stick with a diagnosis that you can prescribe pills for.

I chastised another psychiatrist for not being concerned about brain damage issues. He said that he worked for the mental health system, and they absolutely did not fund for that issue. That would be something the activists would have to work on if they wanted that. He said it with such complacency, so thoughtlessly… but I won’t print his name, either.

In part two, I’ll provide a heap of mini-examples from society in general, just to set the tone, then move into some disturbing clinical examples.

The space between who that person was and those symptoms was palpable, airy, freeing. He did not identify with his mental illness. It sounded like one among many things in his life — perhaps one that at times becomes pretty big and in need of a lot of attention but by far not the defining characteristic of who he is.

Listening to the other speakers, I heard the same theme. They were stories of success and vitality, about how they’re volunteering, working, spending time with other people. Not one of them belabored their mental illness, and every one of them had an almost casual way of referring to it, as something definitely worth mentioning but nothing extraordinarily important.

One person, who is now part of a very successful team that teaches government agencies and the public about “mental health first aid” briefly touched on a diagnosis of multiple personality disorder “associated with experiencing severe trauma in childhood.” The message I heard was not that there was some horrible illness but that a condition like that could easily be expected after this trauma, just like a broken bone could easily be expected after falling from a tree.

Another person referred to her illness simply in terms of “hospitalizations.” Even though it looked like these moments had severely disrupted her life, I was again left with the impression that this was not what her life was all about. It’s so much bigger than that.

We all have varying degrees of abilities and health. What counts is what we make of it. And what we make of it depends so much on what story we tell ourselves and others about our experiences. We can concentrate on talking about what doesn’t work — or on what does and will work; we can use labels for ourselves and others — or we can find our very own words to describe what’s going on.

We can write our own scripts.

And I sure liked those scripts yesterday.

What a Shame About Me

Perhaps the biggest problem with attention deficit disorder (ADD or ADHD or AD/HD or ADD/ADHD), is that superstitious and stereotyped social attitudes keep people from focusing on results and cultivating gifts in order to make a positive difference in people’s lives. As with many “invisible” problems, people with ADD are vulnerable to mistreatment by their parents, teachers, peers, justice system, and so forth. Of course, if the person with ADD doesn’t understand their ADD well enough, they can be pretty nettlesome, too.

Maybe it shouldn’t be called attention deficit, since that makes people think ADD folks can’t pay attention. They often have trouble paying consistent attention to certain things, but are able to “lock on” to other things for countless hours with mystifying stamina, and I’m not just talking about entertainment or easy stuff.

ADD is a very individual thing. The key to understanding a person’s ADD is to know their real strengths and weaknesses, and that includes any mild or not-so-mild learning disabilities or processing disorders that might be along for the ride.

For many folks with ADD, listening to multi-step instructions and remembering all the steps is a real challenge. It’s like making a tape recording, snipping out pieces here and there, and playing the tape for the person. Good accommodations for this problem include providing written instructions, or recording the instructions so they can listen several times. Unfortunately, it looks to me like most employers consider the such accommodations a hardship (I have spent a good number of years in employee assistance). But then, if a corporation can get away with not accommodating a disability, I guess that automatically makes the requested accommodation a hardship.

Am I too cynical? Then consider the amount of advocacy, legal wrangling, and legislation needed to secure basic rights for disabilities–rights that are hard enough to protect for people who have “socially acceptable” disabilities.

I’m not saying that every job can be made ADD-compatible any more than I’m saying I’d make a good pole dancer or Hooters waitress. But many people with ADD could contribute much more if only there were some basic accommodations and understanding. Employment is a huge issue for ADD.

Are People with ADD Lazy?

Many people with ADD work very hard to fill in the gaps that ADD creates. The feeling they describe, of fighting for motivation to do certain tasks, happens to match brainwave changes, as the brain sort of looses its footing, not making enough fast waves.

Actually, the person with ADD, in most cases, would do just about anything to be able to snap to as needed. That’s why some ADDer’s go out of their way to get more excited, even if they don’t know why they do it. They are trying to boost their performance. Unfortunately, they may be coming off as dramatic, eccentric, cocky, irreverent, or just plain irritating when they do that. If they’re lucky, they are perceived as innovative, sexy, compelling, passionate, saintly or enthusiastic. Some of their favorite methods are music, self-imposed deadlines, and coffee.

Society doesn’t give an A for effort, though. If you focus on what you’re excited about and poop out too much on other things, it looks like you’re just being difficult or irresponsible. One fellow who tried to get some consideration for missing his tax deadlines on the basis of ADD didn’t get anywhere with the judge.

With ADD, the amount of will power needed to carry out tedious tasks can be such a contrast with the elation of doing what makes you feel with it and in control, that many people with ADD need a lot more than a to do list to master this problem. This is hard for most people who don’t have ADD to understand.

Sometimes, the tedium will cause a zone-out effect called microfocus. You know this has happened when you’ve lost track of time while grouting your tile, and suddenly it’s time for your kid’s birthday party. Quick! Somebody get a cake! Oh, and presents!

Are They Bad?

On top of that, the symptoms come and go, and the limits ADD imposes are not always triggered. This means the person’s performance can go up or down a great deal. This causes people to tell ADDer’s that they don’t have ADD, that they’re making excuses, that ADD doesn’t exist, and so forth. This also explains why ADDer’s who haven’t looked deeply enough at their own patterns keep being taken by surprise when they botch something or miss a deadline. It’s like not understanding that you’re blind, and wondering why you keep walking in to walls. How come other people don’t walk into walls? It must be because I’m a bad person! I know, I’ll try harder!!!

ADD just isn’t as easy to see as dandruff. It isn’t even easy to imagine as a germ. But it’s really hard to see germ dandruff.

Ooopsie, my mind was wandering again. I smell something burning. It’s the rent check. I must have given the landlady the pizza!

According to WHO officials, factors such as demographic change, natural disasters, internal and external conflict and socio-economic conditions have afflicted individuals living in the developing world disproportionately in terms of the mental health disorders these elements have engendered. In an unprecedented move, WHO organizers invited people living with mental disorders to the Forum, in an attempt to place a “face” on an issue which has been a focal point for global, social stigmatization.

Before the commencement of this Forum, WHO officials addressed mental health issues in 2001, citing it as an area of public health that has not been adequately confronted by member states. In an attempt to arrive at a resolution for improved worldwide services, the forum examined global models for mental health care, ultimately concluding that a network of community mental health services may provide more effective, and less exclusive services as compared to regional mental hospitals.

Dr. Catherine Le Galès-Camus, Assistant Director-General of WHO’s cluster on Noncommunicable Diseases and Mental Health, stated in a WHO press release,

This topic should matter to everyone, because far too many people with mental disorders do not receive any care. The immediate challenge for low income countries is to use primary health care settings, particularly through community approaches that use low-cost, locally available resources to ensure appropriate care of these disorders… The challenge is to enhance systems of care by taking effective local models and disseminating them throughout a country.

The question that remains is whether this rhetoric will materialize on a local and rural level and more importantly, if these initiatives will prove to be feasible in a global setting.

Reference

World Health Organization. (2007) Community mental health services will lessen social exclusion, says WHO. WHO Media Center Notes.

Health professionals have always been taught that chronic neck and back pain is a phenomenon of industrialized nations. The words “Worker’s Comp” come to mind when thinking of the patient who comes in for a complaint of neck pain or low back pain. “Worker’s Comp” has become a pejorative term in medicine, clearly indicating the stigma associated with patients who have back or neck pain.

New research published last month reveals that those patients who have persistent neck or back pain often have an underlying mental illness that needs treatment. The data from this study was from the World Health Initiative Survey on Mental Health and included over 85,000 patients from 17 different countries, including the Middle East, Africa, Asia, and South Pacific. The report specifically found an increased risk of anxiety, mood, or substance disorders from patients with chronic neck and back pain. This phenomenon held steady for both industrialized and non-industrialized countries.

What is interesting about these findings is that it actually validates the many opinions of primary care providers – that patients with chronic pain often have other underlying neuropsychiatric issues that may be affecting their pain. Whether the illness is a cause or effect of the chronic pain is unclear, but there is some association there.

I hope this data helps providers hone in on mental health in their patient history. Hopefully, we will start detecting mental illness earlier to prevent problems in the future.

Reference

Demyttenaere K, et al. Mental disorders among persons with chronic back or neck pain: Results from the world mental health surveys. Pain 2007 Mar 8.

A patient with a history of chronic pain (usually back pain) and pain medication use comes to the hospital for surgery. Post operatively, the patient’s pain is poorly controlled, despite administration of high doses of morphine derivatives. On examination the patient is extremely tender to touch, in areas remote to the operative incision. Both the medical team and surgical team are uncomfortable administering higher doses of medication. They prefer to consult the pain management team, referring to the pain as “neuropathic.”

In the medical profession, we are bothered by patients with neuropathic pain for several reasons. Most obviously, we get frustrated that we can’t make them feel better. Despite high doses of medications and bedside counseling, we can’t seem to ease their pain.

The main reason we are frustrated is that our mission is to make people get better. We tend to overlook the simple fact that pain is a subjective phenomenon. What is painful to one person may not be as painful to another. When we administer high doses of pain medication to no relief, we get suspicious of our patients as drug seekers. We don’t want to promote drug seeking behavior, despite not really knowing what it is like to have uncontrolled pain.

Perhaps the worst thing about medicine is that once this term makes it in a patient’s chart, it follows him or her forever. The stigma associated with having chronic pain issues can considerable alter a patient’s pathway of care. Doctors tend to shuffle problematic patients to those providers that are capable and willing to participate in their care.

Most of the health care providers I have dealt with who are comfortable with neuropathic pain patients are pain management specialists, neurologists, rheumatologists, and physiatrists. Unfortunately, the rest of us seem to perpetuate this stigma throughout the healthcare system.