Nursing Diagnosis: Disturbed Body Image

I'm struggling with body image - I know, at this point, I'm well into the "athlete" range for leanness...and I've lost 9 inches off my waist - my waist is now the size it was when I was in high school, and I was thirty or so pounds lighter, then. I'm all thighs and butt and back...I look like I do the physical activities I do.

Even my mother doesn't think I'm fat (the last time she thought that I wasn't fat was when I was starving myself in high school). I'm down over thirty-three pounds, and I still think of myself as fat. Part of it is having internalized the stupid BMI - which just doesn't work for someone who is an athlete in a sport based around strength and rate of force development, and who is a martial artist - but I think part of it is a really fucked up body image.

Even when I was starving myself, couldn't regulate my body temperature, and would collapse if I stood up too fast, I thought of myself as fat. That was high school. After high school, I went to college, got depressed, and ate my feelings, literally, and used being fat as armor for well over a decade. I could act like I didn't care and used food to feel better. Getting healthy, fit, and lean, in some way, has made it harder - because now I care, and no matter how much someone compliments me on improvements to my health, on my strength, or on my looks - I dismiss it and minimize it. I'm tired of watching every bite of food that goes into my mouth - like, I need, very soon, to say "my body's good" and let myself relax about it sometimes. Drinking a glass of wine or eating a couple squares of *gasp* only 75% cacao dark chocolate and feeling guilty about it is no way to live.

So much of what I have to work on right now is mental - I need better body image, I need to not be afraid to pull myself under the bar (which is seriously holding me back - as soon as the weights get heavy, I stop pulling under the bar fast), I need to be realistic in that...I'm 32. Even if I had the potential to ever be competitive in a serious way as an olympic lifter (and I'm talking "qualify for nationals" competitive, not "olympian competitive"), I should have started over 15 years ago, more like 20. Now it needs to be about personal fulfillment and personal improvement - so I need to not give so much of a fuck about finding the best weight class for me, or finding how absolutely little fat I can carry before I fall apart as an athlete. I need to just eat healthy most of the time, lift, do Aikido, and enjoy the athlete and non-athlete parts of my life.

Thanksgiving, Food, and Not Feeling Like A Huge Jerk

It's weird - I spent 20 years dealing with serious illness, only to learn that it was caused by gluten all along. Even though I have access to care, I don't trust the healthcare providers I have access to to have gotten the testing done promptly enough to distinguish between non-celiac and celiac gluten sensitivity, as I've likely mentioned. Also unfortunately for the timing of the realization, I couldn't yet be foolish and order lab work on myself (board certification as an NP is still a year and a half or so away). And it's not worth being seriously ill for a couple of months to determine something that will have the same outcome.

I bring up this detail again just because not having a lab test makes me feel like a huge jerk when I have to turn down things, even though, ultimately, the test is "does gluten exposure make you sick after long-term avoidance?"

Thanksgiving is frustrating in that it revolves around food. As an ex-vegan, I'm used to this level of frustration, but I think it's a little easier for people to get "I don't eat animal products because of an ethical stance" than "I can't eat anything that is contaminated by gluten because I'll get really sick". Thus far, I've experienced pretty decent respiratory symptoms from being in the same room as flour being mixed into dough (yes, that sensitive), fortunately learned the turkey had had flour put on it before roasting, and then had to explain several times that no, I can't just eat around the skin, and then saw the leftover pie I made put in the same container as the gluten-y desserts, which has the side benefit of sparing me from binging on more pie.

It doesn't help that two people in my family are "avoiding gluten" as a diet, but will still drink beer, have small amounts of gluten-containing foods, and not worry about contamination. It also doesn't help that family sees me not as a healthcare provider, who knows enough to say "intestinal biopsy would have been ideal, but the obvious dx is severe gluten sensitivity of some type", and who consulted with other healthcare providers who concurred.

I'm really fortunate in that two of my three housemates also avoid gluten, and the third is super good at cleaning...because I could, obviously, be getting glutened all the time. 

So, yeah, Thanksgiving was hard, and frustrating, and I felt like a jerk for making people feel like they made stuff wrong, or asking questions about the exact ingredients of everything...and it's not like I don't have enough issues around food (and weight, and body image) to begin with (the "I still think I'm fat when even my mother doesn't" post goes into the queue with "more talk about gender"). Just, even with people who have seen how sick I was from the age of twelve or so on - twenty years shaped by chronic illness - it's almost possible to get them to understand that "gluten contamination" is way less of a concentration than what would be visible to the eye. It makes me worried about a) how do I explain it to people who didn't see how sick I was - and see a fit and healthy thirty-something who has a weird diet and b) how do I support my patients who have celiac or non-celiac gluten sensitivity (which is incredibly common), and give themselves the tools to help themselves remain healthy?

As a personal aside, it turns out my prior issues with dairy were due to my gut being damaged at the time - I don't have cross reactivity to casein, which is a huge mercy. This opens the door for paleo being a template or a method that I make work for me.

Updates

I'm horrible at keeping up with this but...

1. I finally accepted that food was the root cause of my health problems - I had gotten sicker being vegan (again, it's been a pattern - being veg*n relies on foods I can't handle, especially when one is short on time), but this time my bloodwork was near immediate crisis. I knew that I got sicker every time I went veg*n (especially vegan), and I knew I had some level of problems with gluten and soy - I just hadn't been strict enough to find out how much. After some experimentation, I have a severe gluten intolerance (to the extent that going back on to determine whether it's celiac or non-celiac isn't worth it - even a very small amount of gluten would have me sick for days - so it's 100% avoidance) - what looked like fibromyalgia, chronic complex migraines, chronic sinusitis, horrible skin, IBS, and even the bouts of what looked like systemic inflammatory arthritis were all gluten, and all were gone within a week. There's a moderate soy intolerance in there as well, and a bit to corn. My GI system definitely didn't like any legumes at the time, but who knows what would happen if I tried them again (I'm not eager to). 
2. I was becoming pretty rapidly insulin resistant on a vegan diet (blood glucose was fine, but triglycerides through the roof and energy fluctuations all over the place), so I pretty much had to break the carb addiction. Needless to say, with all that going on, to even get in the ballpark with a healthy diet, I'm eating animals. Six months into that, and three months into cutting out all grains, legumes, and (except on exceedingly rare occasions) dairy, I'm still dealing with eating them everyday on some level.
3. This is the healthiest I've been in about two decades.
4. I finished the RN portion of my program the end of July, and took and passed the NCLEX in early September.
5. I'm now in the MSN portion of my program. This semester is brutal, as in the family specialty, we have almost no clinical (6 hours of newborn assessment, and 6 hours of geriatric assessment), just endless hours of class. We make up for it by overloading on clinical in the spring and next year.
6. I'm also TAing Medical-Surgical Nursing. I feel like I'm making positive contributions to my school, but it's stressful.
7. Weight started to melt off with the change in diet, and being not in constant pain and not dealing with a various degree of debilitation everyday for the first time in two decades, I'm back in the gym. I took up Aikido (specifically Yoseikan Budo). Rather than having to constantly work around my body for what I can do with weights, I'm able to really work on getting good at the full olympic lifts. I can also do a lot of mixed modality workouts. It's pretty great.
8. I realized, gender-wise, I was hiding a lot behind the weight - being that heavy made my body look more genderless. Also, even if my body was still viewed as female, being butch didn't offend as much because I was "unattractive", anyway. And there's a certain harder edge to my body now. There's a whole post on gender to be made.
9. I also realized that I was hiding my internalized shit with my own gender non-conformance behind "they"- clearly, with butch as the central part of my gender, I'm never going to move through the world unnoticed...in a way that is always genderqueer. But to steal how Kelli Dunham talks about it, it's more "woman or whatever". In other words, "she" stopped hurting when I accepted I wasn't a failure at being a woman.

Time Moves Fast...

I get home from my trip, and I blink, and I'm three weeks back in school, and already getting to the middle of April. Hard to believe that in about three and a half months, I'll be an RN. We're in the home stretch for the year - a lot of clinical time, and not nearly as much class time. I've seen a birth, and I've held, soothed, and fed newborns who came into the world in a rough way.

Still, my mind keeps wandering back to the West Coast - Portland and the Bay both went far better than I expected, and I miss it. I miss living somewhere where I make sense to people. And I keep contrasting the puritanical coldness and busyness of New England with the laid-back openness of the West Coast. At least spring is here - we've already had a couple of warm days, even if now the weather wants to trudge along in that not-quite-warm-enough-but-not-deathly-cold spring chill.

In Portland and in the Bay, what struck me was how fondly so many people had missed me. It turns out that a lot of what I thought would be the case was just my paranoia. People out there helped me realize I haven't become a different person, I'm just a more grounded, more even-keeled version of myself. A me with an actual longterm plan that is in motion, which, sad to say, is a new thing I'm doing in my thirties. I guess I'm finally getting really responsible, rather than living hand-to-mouth, day-to-day.

What keeps me going here are the crew of people I'm around. My class, we've all formed various bonds with each other. Some I'm close with, some we mainly just have the connection of going through this intense rollercoaster of a journey together. I can feel myself letting my guard down, bit by bit, as time goes on, learning to trust, learning that I can have a place in the world that isn't so damn marginal all the time. It's terrifying, but it feels good.

On the Bus.

So, I'm on a bus between Seattle and Portland. Seattle was magical: friends new and old, lots of amazing food, and the happy coincidence of running into old friends (also on tour) due to the statue of Lenin, which led to friends realizing I was within a couple of blocks. It was a few awesome days capped off by singing at karaoke night at a vegan metal bar (Highline in Capitol Hill. Get the poutine and the High on Fire off the cocktail menu. Trust me).

It was good to start somewhere I was a bit familiar with, but hadn't lived. All my past memories of Seattle have been good. I'm a little worried about what Portland might drag up for me - I was really a hot mess when I lived there a few years back. There's definitely stuff from my past I haven't dealt with, and a couple people I wasn't on the greatest terms with.

Anyway, we're there less than 48 hours, so it will there'll be even more to see and do that I won't get to. Hopefully the book event tomorrow evening will be as positive as the Seattle event was.

Another Batch of Classes Down

And I'm done with another batch of classes (semesters are a polite suggestion in this year of my program), over halfway through the chaotic first year of my program, and over halfway to being an RN. As tough as the last two years - the traditional MSN program culminating in becoming an APRN - will be, they'll have a much more regular rhythm to them. It's also been the half-semester where I've had the most outside stress, the most going on with myself, that wasn't directly about the courses and clinicals. I asked for help when I needed it, supported other people with whatever they had going on, and we all got through it together.

Now for my spring break trip to the West Coast and speaking tour!

Two Steps Forward, One Step Back (Isn't Even That Great of a Metaphor)

Yesterday evening, I got pretty deeply triggered, and stuck in some old trauma. We experience trauma not only from things that happen directly to us  - "I was hurt, I could have been killed, my boundaries were deeply violated" - but also from what happens to the people around us - "I see her being hurt, I see him almost being killed, I see them being targeted"- and in our experiences of helping other people to deal with and start to heal from their own trauma. This vicarious trauma is just as real as what we directly experience - by seeing other's pain, and by working with them on it, to do this at all, we need empathy. And to do it well, we need a great deal of compassion, a word that comes from the Latin for co-suffering. None of us (healers of any sort) get in and stay in this for the money; a lot of the actual work of helping people heal is unpaid, and a lot of the most physically demanding jobs in health care are poorly paid. The well-paid work requires extensive education, and there are easier ways to make a buck with that level of education. We are healers because we can't not be - we see suffering in others and we can't help but want to help alleviate that suffering.

But in addition to the toll the conditions of our work can often take on us - the modern hospital can look a lot like a factory floor, and everyone has too many patients, and too much they're supposed to do for them to not, at the very least, be completely worn down by the end of the shift - the trauma we bear witness to everyday takes its own toll, and can bring our own trauma back to the surface. And it doesn't necessarily matter how similar or different our experiences are - caregiving is emotionally intense work, and being truly present and compassionate means that we're going to be affected by what we witness.

So, back to the title of this post. I'm really fond of telling people that recovery from emotional trauma isn't linear, and that doesn't just mean we'll occasionally have setbacks. To present the analogy of a physical wound, a wound can be fresh and bleeding - that's acute trauma. It can also be oozing a bit, still not through the initial healing process, where we hopefully process it and recover enough to go on with some sort of regular rhythm of life, whether it's the old one or a new one. Or it can be an old scar, that we think we're through with...but sometimes we have to break up old scar tissue because it's putting restrictions on our life, and sometimes scars ache.

Just because we're breaking up that scar tissue - or even if some change in our life makes that scar ache intensely - doesn't mean we've taken too many "steps back" in our own process of recovery. And forgetting that lesson, that truth that I've told so many other people, had me beating myself up for a while - something that was far more harmful to me than being triggered - until I could say to a housemate that I had gotten triggered, and was greeted with acceptance and concern, and not judgment. Only then could I realize that I wasn't treating myself with acceptance, but with judgment.

Burnout is an ever present danger for caregivers - in the past, when I was street medicing intensely, and supporting people who had gone through incredibly traumatizing experiences, I began to feel it not when those things made my own experiences of trauma ache, but when I couldn't accept those aches as a part of being human. Instead, I saw them as a weakness on my part. Being a strong, competent healer doesn't mean never suffering ourselves - it means being able to be compassionate to others, and then, going and being compassionate toward oneself. If I'm not being compassionate to myself, I'll have too much going on with my own emotional wounds to be able to put my own concerns aside while I'm working with someone else - and I won't be able to make, in the moments I'm working with them, their own needs my true focus. As my own unprocessed trauma piles up, I'll be a patient trying to take care of other patients, and the first rule I learned about street medicing is "don't create another patient".

I think the most important lesson I've been taught in the last couple of months was one thing a preceptor had us repeat when she was showing us Emotional Freedom Technique ("tapping") - every time she had us mention an anxiety we had, it was always in the form of "even though ______, I completely love and accept myself". No amount of intellectual understanding of how our own experiences of trauma work, and how we can be affected by vicarious trauma can replace telling that message to ourselves like we mean it, until we really mean it.

More and more, I think the two best guardians against burnout are, first, not pushing down our own feelings, and, second, being part of a community that will remind us that we need to be compassionate toward ourselves when we forget to be. Learning to say "yes, even though I have witnessed suffering, and that suffering sometimes stirs up my own past experiences of suffering, I completely love and accept myself. The scars I bare are a part of what makes me the person I am today, a unique being worthy of compassion just like every other human being. I completely love and accept myself, scars and all" is vital. I could probably do this work for a while without completely loving and accepting myself, scars and all - but to do it for a lifetime, compassion needs to not be a solely outward facing thing, and I'm glad I've got people in my life who will remind me of that anytime I forget. After all, I do the same for them.

Opening the Heart

It's fair to say I've been having a pretty rough time as we power through the second half of our marathon RN year of nursing school. A significant part of the problem for me is that I've been so immersed in the world of western allopathy that on a deep level I've been losing touch with where I came from. That disconnection from an approach that is both holistic both on the personal level and on the level of society and nature has even strongly affected how I do self-care. I'd started falling into a pattern where I would see various self-care practices like pills - do activity X to deal with complaint Y. Which is neither fun nor particularly effective.

Psychiatric nursing has probably been where this conflict has been most intense. On one hand, in my clinical rotations, I'm praised for my wariness of the mental health system and my seeing patients as having their own unique experiences of trauma, extreme mental states, and so on, where the psychiatric diagnosis is a contested and shifting attempt for a flawed system to get a handle on people. There, my seeing the common humanity and the connections between myself, my fellow students, the staff, and the clients is praised, and I feel like I'm being drawn back to the calling that got me started on this road in the first place: assisting people in healing and integrating their experiences of trauma.

In psych lecture, I see people continually reduced to diagnoses, and get drilled on the outdated even by the standards of mainstream psychiatry standards that the NCLEX tests on. I constantly feel the subtext that the patient is The Other and that nurses, psychiatrists, and the whole host of other mental health providers are never, ever, patients. The patients are "ill" and the providers are "well", and never the two shall meet. And, continually, in the back of my mind, I think "am I allowed to give care anymore? Or am I too broken?" when all the scarred over wounds were a big part of what made me good at what I do in the first place.

Hopefully these two opposed experiences will resolve into making me a more skilled and more compassionate nurse, rather than someone who runs away screaming from psych, because no matter what exact road I take, I want to help my future patients by integrating care of the body and mind. I've been trying to consciously get back to my roots lately, returning to herbalism. And approach to herbalism of helping the whole person return themselves to balance, both internally and with the world around them, rather than a set of knowledge about plants to be used like western allopathic medications, except "natural".

So I read this wonderful account about hawthorn, and when I got home at the end of a long day, I took all the jars of tinctures and dried herbs out of the bin I'd stored them in, and got busy reorganizing them, which started out looking something like this:

Thankfully, I subsequently got it a lot more organized, and pretty quickly identified the tincture that had leaked a bit as elderberry (which is a pretty easy one). With the herbs sorted and a few empty tincture bottles refilled, I took 2 ml of hawthorn berry tincture.

Immediately, I felt an emotional/spiritual tightness around my heart lift, and all these feelings that have been just sitting there, endlessly being analyzed but not being allowed to do what feelings are for - being felt all the way through, from beginning to end - get gently on their way.

Now to put some mugwort under my pillow and take a bath scented with an essential oil or two and actually relax, for a change.