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Wednesday, January 16, 2008

A New Concept: Patient Self Management

According to the Centers for Disease Control and Prevention (CDC), more than 90 million Americans now live with chronic diseases. These chronic diseases as diabetes, and arthritis result in a decreased quality of life, limited activity, and extended pain and suffering.

When you suffer with a chronic health care problem, you deal with many factors that compose that problem. Some of these factors overlap, augment each other, or oppose each other.  And each factor may call for its own physician or treatment. If you want to succeed in your quest for wellness, the first thing you must do is drop out of the  "I just do what my doctor tells me" school.

Join your health care team. Indeed, take over:

  • Take responsibility for self-monitoring,
  • introduce better health behaviors into your life
  • Become a collaborative decision-making partner with your physician(s).

Any why not? You have the disease, not your doctor.

Growing evidence supports your role as a collaborative team member and captain. Remember, about 90 percent of what's needed to help you improve comes directly from you, the person with the chronic health disorder.

When you become a team caption on your health care team, your care will improve as well as your satisfaction as a patient.

To learn more about the growing area of "patient self management," check out the Stanford programs on self management by clicking here.

Wednesday, December 26, 2007

The Writing Practice Prescription

It's time to think outside the pill box.

Sir William Osler had a lot to say about this:

  • "One of the first duties of the physician is to educate the masses not to take medicine."
  • "Man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. The desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures."
  • "If many drugs are used for a disease, all are insufficient."
  • "The battle against polypharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into the bodies of the action of which we know less), has not been fought to the finish."

The most important thing he had to say about thinking outside the pill box was this: "The true polypharmacy is the skilled combination of remedies."

After having used personal expressive writing for years to be more productive and focused, I stumbled upon the work of James Pennerbaker, PhD and colleagues who have demonstrated that expressive writing when focused on past traumas can improve health status.

At the time I came upon their work, I was directing a Violence Intervention Prevention center at Parkland Hospital in Dallas, TX. The majority of patients we cared for were victims and survivors of domestic violence. It soon became clear to me that the survivors carried the burden of the health consequences of their abuse, mental as well as physical. As a result, I wrote a book for survivors of trauma and abuse called WellWriting for Health After Trauma and Abuse. The feedback from readers remains encouraging and convinces me that we should probably be handing patients paper and pen to speed their own recovery.

Saturday, June 16, 2007

Know Your ACE Score

By

Ellen Taliaferro, MD

Can the woes and traumas of your yesterdays take a toll on your state of health today? Indeed they can and do.   At least that's what our grandmothers always seemed to know.

Now, thanks in large part to the Adverse Childhood Experiences (ACE) Study, medical research validates this concept. Dr. Vincent Felitti, Founder of the Department of Preventive Medicine in Kaiser Permanente in San Diego, and his colleagues at the Center for Disease Control and Prevention (CDC), have identified ten adverse childhood experiences that correlate with adult health status half a century later.

What are adverse childhood experiences? To date ten have been identified in children younger than 18 who grow up in a household with:

  • Recurrent physical abuse
  • Recurrent emotional abuse
  • Sexual abuse
  • An alcohol or drug abuser
  • An incarcerated household member
  • Someone who is chronically depressed, suicidal, institutionalized or mentally ill
  • Mother being treated violently
  • One or no parents
  • Emotional or physical neglect

Any one of the above ten items receives a score of one, no matter how many times it occurred. For instance, if you were sexually abused once or many times as a child, your ACE score is one and only one. The higher your ACE score, the more likely you will be to experience a wide range of health and social problems in your adult life.

Recently, Dr. Felitti spoke in San Mateo, CA, and presented an overview of the findings from the ACE Study. He noted that the official questionnaire for determining an ACE score was several pages long and needed to be professionally evaluated. However, recently the ACE Study Group developed a "self-test" version of the questionnaire. This survey has only ten questions and can be explored and taken by clicking the link below.

Click here to download a copy of the ACE survey

 

Tuesday, October 17, 2006

Writing Your Story--Even if It Doesn't Feel Good at the Time

The stories of our life drive us. And yet, so many of us don't even know what our stories are. Long forgotten trauma may be the story denied that we live with. Sometimes the stories are so painful and remarkable that they are far from hidden. There's no need to explore your inner universe to find them. They blare forth like neon lights.

We know now from the medical literature that Well Writing™, a form of directed expressive writing can enhance the immune system, help overcome various forms of chronic pain and even reduce symptoms in asthmatic and rheumatoid arthritis.

But being better and feeling better, don't always happen at once. For instance, Koren Slicks, author of Smashed: Story of a Drunken Girlhood, wrote her book once painful memories began tugging at her. She later noted, "It's hard to say the writing process was therapeutic. (While writing) I cried a log. I was very emotional while writing." But the aftermath was rewarding when she later discovered how meaningful it was for her to be able to give book readings on university campuses and finding out that many of the coeds were going through the same experience she wrote about.

I call this a reverse Mary Poppin's experience. First you take the medicine (yuk!) and then later, sometimes much later comes the teaspoonful of sugar.

So. For now, my prescription on handling painful memories stays the same: Write. Write. Write.


Friday, November 25, 2005

Animal Abuse and Family Violence

ANIMAL ABUSE, DOMESTIC VIOLENCE AND CHILD ABUSE:
The Traumatic Links of Family Violence


By

PHIL ARKOW
Interim Director, Human-Animal Bond
The American Humane Association

A compelling body of research is drawing renewed worldwide attention to the links between animal abuse and other forms of family violence. These findings are confirming conventional wisdom that in homes with violent behavior, caseworkers often encounter multiple forms of abuse.

When an animal cruelty, child protection services or domestic violence law enforcement officer conduct investigations, they often will see two or more forms of family violence. They need to have pre-established lines of communication to make referrals to other agencies. This recognition and cross-reporting is critical if we are to stop family violence. When animals are abused, people are at risk, and vice versa. Often, the choice of victim is opportunistic, and whether the victim has two legs or four is a matter of availability.

What we call “The Link”is based on several premises. Because animal abuse may be more readily observed and reported by victims and witnesses, animal welfare investigators are often the first to respond to family violence and the first point of delivery of social services for families in crisis.

Second, thousands of women are trapped in abusive environments out of fear for what will happen to their animals if they leave. Similarly, children’s pets are threatened if the child does not
participate in sexual abuse, or talks about it.

Third, animal abuse often co-exists with other crimes. Police in Chicago have found that more than one-third of their arrests for dog fighting also result in charges for guns, drugs, or gang violations.

Fourth, childhood acts of cruelty to animals are among the earliest “red flag” markers for conduct disorder and signs that a child is heading down a violent road. A dangerous lack of empathy for others often ensues.

Trying to define animal abuse, which varies widely by cultural and historical standards, is a challenge. The U.S. has the world’s oldest anti-cruelty laws (dating to 1641), but it’s like defining pornography -- impossible to describe, but you know it when you see it.

Because “cruelty” implies malicious intent by the perpetrator, which is difficult to prove in a court of law, I prefer the term “animal abuse,” which implies that maltreatment occurred regardless of the perpetrator’s motives. Animal abuse encompasses harmful actions ranging from abandonment to dogfights to hoarding to physical injuries. However, because animal abuse is a crime representing only harm to another’s property, and because the psychological motivations for people committing these acts vary widely, legislators and the courts are reluctant to enact and enforce greater protection for animals. The result is a low community priority for animal welfare.

Research in the 1970s identified cruelty to animals, arson and bedwetting as a triad of behaviors highly prevalent in the childhood histories of sociopaths. In the 1980s we found that most serial killers had committed atrocities against animals in their childhoods, acts that were ignored under the apology that “boys will be boys ” instead of seeing them as potential “red flag” markers.

In the 1990s, we learned that 50% of school shooters have histories of abusing animals.

It’s often assumed that harming animals is the first step down the slippery slope of desensitization, but a 1997 Massachusetts study found not only that 70% of animal abusers had records for other violent crimes, but that 56% of these abusers committed their other crimes before the animal abuse. This tells us that animal abuse is a complex constellation of dysfunction.

Several studies reveal that over 94% of animal abusers are male, and almost 1/3 of cases are committed by teens. Women are responsible for 68% of animal hoarding cases. 21% of animal abuse cases involve other forms of family violence. And while three-quarters of the victims are pets, farm animals and wildlife are also at risk.

Although the child protection movement emerged from animal protection in the 1870s, the two groups have largely pursued parallel paths without much interaction until recent Link research refocused attention on the commonalities of all forms of family violence. In a 1983 study in New Jersey, researchers found that 88% of families investigated for physical child abuse also had abused or neglected pets. This study also found that there were 11 times more dog bites in these families than in non-abusive homes, and that these abusing households see veterinarians at rates almost equal to non-abusive families, forcing us to recognize that veterinarians will see abused patients and clients.

Research is focusing on the links between animal abuse and domestic violence. From 25% to 40% of battered women delay their decision to seek safety because they fear for the safety of the animals they are forced to leave behind. In one study, 71% of women entering safehouses reported their batterer had killed, harmed or threatened animals; 32% said their children had harmed or killed animals, further testimony to how the cycles of violence are intergenerational.

Other studies describe The Link in rural environments. One victim reported, “My husband said if I left he would kill the dog and let the calves die and it would be my fault. When he threatened to kill me, I thought, who would know? The farm is so isolated.”

There are links between animal abuse and elder abuse. 35% of Adult Protective Services caseworkers report their clients talk about their animals being harmed or threatened. 92% see animal neglect co-existing with their clients’ inability to care for themselves.

People outside the animal field often trivialize our work because they do not realize how prevalent pets are. There are more dogs in America than there are people in most European countries – and more cats than dogs! A child growing up in America is more likely today to have a pet than a father. More American households have pets than have children. We spend more money on pet food than on baby food, and the pet industry is our 7th largest economic sector.

This is not to say that animals are more important than people, but rather than in a civil society no family violence is to be tolerated.

We can make three key points about The Link:


  • First, animal abuse must be perceived and documented as a human welfare issue.
  • Second, animal abuse must be redefined as family violence.
  • And third, the network of community caregivers – including veterinarians – must be cross-trained to recognize and report all forms of family violence to agencies empowered to investigate and prosecute it.

Many steps are being taken to protect the health of all family members after these traumas. Psychologists are describing the profiles of animal abusers. Veterinarians are developing clinical criteria to recognize Non-Accidental Injury, similar to manuals developed years ago to help physicians identify the stereotypical bruises, burns and fractures of physical child abuse. Legislation in 42 states has made serious animal abuse a felony. Animal protection officials and veterinarians are being added to the lists of those mandated to report suspected abuse. Several states require persons convicted of animal abuse to undergo anger management or psychological counseling, community service, or to be prohibited from owning pets.

Women’s and animals’ shelters have established “Safe Havens” – foster care programs for pets to remove one barrier to a woman’s escape.

Federal funding is available for community coalitions where human and humane service agencies train each other to recognize and report family violence. A bill pending in the Canadian Parliament would redefine animal cruelty as a crime of violence rather than a crime against property.

Veterinary codes of ethics in the U.S., Canada, the U.K., and New Zealand now address The Link. These codes say vets have an ethical obligation to resolve family violence through education, but where such education fails, disclosure may be necessary.

Intervention programs pair juvenile delinquents with homeless dogs from shelters; the teens learn non-violent conflict resolution through training dogs to be more adoptable.

Battered women are encouraged to include their pets in their “Safety Plan.” Public education campaigns are teaching communities that the parent who comes home and kicks the cat is just warming up.

Excellent resources are available from American Humane (www.americanhumane.org) and the Latham Foundation (www.latham.org). Documentation of animal abuse cases and bibliographies are available at this link.

In 1962 the “battered child syndrome” entered medical terminology. In 1979, Lenore Walker wrote “The Battered Woman.” In 1996, Helen Munro coined “battered pets.” We have made much progress in a short time, but we have more to do.

Family violence is a matter of power and control. Often, the choice of victim is opportunistic. Whenever one member of the family is abused, all other members of the family are at risk.

Dr T notes: you can communicate with the author of this piece at Phil Arkow

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DrT Speaks

  • Responding to domestic violence in the healthcare system.
    Features the strategies needed to identify and respond to victims of domestic violence. Provides methods to integrate domestic violence screening into practice and the medical history. Covers medical documentation using charting, body maps, and photos. Safety assessment is stressed, as well as appropriate referral of patients who are victims of domestic violence.
  • Understanding Domestic Violence: Why we need a medical response
    An in-depth overview of domestic violence, often referred to as intimate partner violence (IPV). Addresses commonly held myths and misconceptions. Presents the impact of domestic violence on patient health and the medical system.

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