Saturday, January 30, 2010

Prozac is Talking -- Anybody Listening?

Anybody know this story?  You get a new prescription.  Responsible consumer that you are, you read carefully the PI [prescribing information] sheet.  It says, "If xx happens, call your doctor immediately."  Sure enough, xx happens.  You call your doctor, who does not call back.  After persistent calling over several days, the doc says, "Really?  We'll keep an eye on it."

The other day, I had a nosebleed that wouldn't stop.  The PI sheet says my new med can interfere with platelets, admittedly not very high on the list of side effects.  But I contacted the doc.  "Really?"  she said, "Where did you hear that was a side effect?"  My answer, "On the PI sheet you gave me."  It turned out, my blood work was fine, and the humidifier took care of the nosebleeds.

No harm done.  Right?

On the other hand, five years ago my GP had me on Prozac.  After a couple months, I couldn't sleep, was irritated, agitated, couldn't concentrate, had thoughts of harming myself and others.  The PI sheet said I should tell my doctor.  My doctor increased the dose.

Thus began a series of antidepressants, and a downward spiral that has ended with disability.

Actually, my GP was operating by the book.  Eli Lilly wrote the book.  They convinced family practitioners around the world that SSRIs were safe, effective, and an easy solution to an easily diagnosed condition.  After I quit Prozac for a different side effect, and after the second SSRI also made me worse, she followed standard procedure, and sent me to a psychiatrist.

Eventually out of self defense, I started reading more than the PI sheets.  I read the research.

Does anybody out there have a doc who reads the PI sheets?

This is what I read in the doctor's information about Cymbalta (an SNRI), the December 2005 version:

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric.  Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.

These paragraphs were found on pages 7-8 of the 27 page document, appearing after the black box warning about children, the drawing of the molecule, the pharmocodynamics, the pharmocokinetics and the clinical studies.  It didn't just jump out at you.  This version for doctors was published right after the drug companies lost the battle they fought tooth and nail against those black box warnings.

December, 2005 was exactly the month when my second psychiatrist prescribed Cymbalta for me, (relapsed after a period of remission,) some time after the widely reported controversies and clinical studies that led the FDA to require the warning.  She pulled the samples out of her sample cupboard.  Didn't the sales rep give her the doctor's prescribing information?  Didn't she read it?

That psychiatrist didn't answer phone calls about side effects.

Do Antidepressants T(h)reat(en) Depressives? is a review of literature (published in 2006) that exonerates antidepressants from the charge of causing suicidal ideation and behavior.  However, its authors, Z. Rihmer and H. Akiskal do cite several clinical studies from 1999-2005 that identify a particular population besides children at risk: those with bipolar, Bipolar II, anxious depression and mixed state depression.  All these are on a continuum of cycling depressions, with bipolar at one end and recurrent depression at the other.

The continuum's middle, especially Bipolar II is the most treacherous ground.  People with this type of mood disorder are already at an elevated risk for suicide.  Each hypomanic symptom increases the risk of suicidal ideation by 4.2%.  Rihmer and Akiskal report that those who take antidepressants double their risk of suicidal ideation, self-harm and completed suicides over the risk to those with bipolar and triple the risk to those with simple major depressive disorder.

And how was this population and this elevated risk identified?  Largely, by the list of side effects themselves that they experienced, Cymbalta's list above.  Bipolar II is diagnosed after treatments for other diagnoses fail.  A friend discovered that her psychiatrist had added Bipolar II to her diagnosis.  When questioned, the psychiatrist said, "Oh, that simply identifies how you respond to antidepressants."

In fact, Baldessarini, Tondo and Hennen found in 1999 that women with Bipolar II were not correctly diagnosed for an average of eleven years.  (Half of all suicidal acts occurred in the first 7.5 years of 19 years that were included in the study.)

Let's put all this together.  Well, first -- let us recognize that most people with Bipolar II do survive the disease without self harm or suicide.  And with proper treatment, including the correct meds, they can thrive.

That said, Bipolar II is a particularly dangerous form of mood disorder.  People with Bipolar II, already at a higher risk of suicide, increase their risk when they take antidepressants.  Nevertheless, they often do take antidepressants, because Bipolar II is notoriously difficult to diagnosis.  But a major clue to diagnosis is the side effects experienced when taking antidepressants.

In other words, Prozac is talking to you.  So are Zoloft, Celexa, Lexapro, etc. (SSRIs).  Cymbalta and Effexor (SNRIs) are shouting.  If you take antidepressants and are experiencing anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and/or mania, your life is at risk.

  • Take an online screening for Bipolar II, a Mood Disorder Questionnaire (MDQ).  Get the people who live with you and/or are closest to you to answer it with you.  You won't recognize symptoms of hypomania.  They will.
  • Then get a psychiatrist to give you a thorough and careful screening for Bipolar II.  This will take time.  If you have to go out of network to find a psychiatrist who does more than the fifteen minute intake, pay the extra.
  • Ask whether you should quit your antidepressant.  Ask for a mood stabilizer.
  • Check out McMan's Depression and Bipolar Web and its various pages for more information.  This site has more information than Depression and Bipolar Support Alliance (DBSA).  Oddly, National Alliance on Mental Illness (NAMI) has no information on Bipolar II at all.
Because Prozac is talking.  You better listen. 
 
The Scream by Edvard Munch

Thursday, January 21, 2010

The Miracle of Gheel -- Humane Treatment for Mental Illness

It was seventh century Ireland.  The Queen died.  King Damon's grief was so deep that it moved into depression and then psychosis.  He thought his daughter Dymphna was his queen.  Rather than submit to his advances, Dymphna fled to Belgium, to the town of Gheel.  But her father followed.  When she again rebuffed him, he killed her, cut off her head.  Dymphna was buried in the local church.

Six centuries later, her coffin was found during renovations.  Signs on the coffin demonstrated her holiness.  She began to be venerated.  Cures of the sick were attributed to her.  She was canonized in 1247 as the patron saint of the mentally ill.

Okay, here the one last bit of unrecovered Catholic in me demands to be heard, to note Rome's fascination with girls who prefer death to rape.  Even as a nine year old, that made me uncomfortable.

Moving on.  People came to Gheel for healing.  Many brought family members who were mentally ill.  Sometimes they left them there.  The priest housed these abandoned ones next to the church.  When the job of caring for them became too much for him, townspeople started bringing in food.  They built a hospital in the 14th century.  When it was full, the real miracle of St. Dymphna occurred, or rather, began.  Townspeople took some of the patients into their own homes, reserving the hospital only for those most ill.

All across Europe, people with mental illness were thought to be possessed.  They were exorcised, tortured and burned at the stake.  But not in Gheel.

Imagine it!  A psychotic foreigner commits a terrible deed.  But the townspeople do not close the borders.  No, they open their homes.

And they still do.  Through plagues, wars, revolutions, recessions, depressions, during the Napoleonic "Reform," when all the mentally ill people in the country were ordered into one big hospital, during the Nazi occupation, with their "final solution" for mental illness, during the latest reform when the U.S. of A. was/is dumping all our mentally ill people out of the hospitals, onto our streets and into our jails, the people of Gheel developed and continue genuine community-based mental health care.

Today, there are 700 foster homes for 1000 people with mental illness.  A person will enter the hospital for evaluation and stabilization.  S/he meets the psychiatrist, psychologist, nurse, social worker and family practitioner who staff one of the five neighborhood community mental health centers.  Each of these staff people spends half a day each week in the hospital, so everybody gets to know everybody.  The potential foster family and patient meet at the hospital, then over tea at home, then over a meal, then over a weekend before placement.  Outpatient care, medication monitoring and therapy continue at the neighborhood center.  If possible, the biological family participates in the treatment plan.

Once part of the family, the person shares in family activities, chores and church.  The church doesn't have special bible studies, services or programs for the mentally ill.  They are fully integrated, regular readers, members of the choir, ushers, etc.

What if the person's symptoms flair?  "We say s/he is having a bad day."  Because the person lives in a family, not on the streets or alone in an apartment, problems are caught and addressed early, not after getting fired or evicted or arrested or in a bloody mess.  If needed, s/he can go back to the hospital for a while.  In fact, the hospital is not the place of last resort.  When the foster family has to go out of town, say, for a funeral, the person can stay at the hospital.  There is continuity of care.  There is care.

Three years ago I wrote a chapter for Deep Calling called, "If This Were Cancer."  I detailed all the ways that hospice patients receive the support of others, and that people who have suicidal depression do not.  "If this were cancer, there would be casseroles..."  I imagined the total collapse of care for the mentally ill, under the weight of our crazy health care system.  In fact, it's happening as I write.  I imagined that the Church would step in to meet a desperate need, to create hospice for the mentally ill, as the Church originally created hospice and hospitals.  I claimed that the Church has the resources to organize for such care on a local basis.  It has the faith to imagine such a thing, the love to cast out fear, and the values to demand it.  I will have to rewrite that chapter.  I didn't know it had already been/is already being done.

I am ever so grateful to Janet, whose last name I don't remember, who gave me Souls in the Hands of a Tender God: Stories of the Search for Healing and Home on the Streets by Craig Rennebohm, the source of this story.

Lord God, Who has graciously chosen Saint Dymphna to be the patroness of those afflicted with mental and nervous disorders, and has caused her to be an inspiration and a symbol of charity to the thousands who invoke her intercession, grant through the prayers of this pure, youthful martyr, relief and consolation to all who suffer from these disturbances, and especially to those for whom we now pray. (Here mention those for whom you wish to pray.)

We beg You to accept and grant the prayers of Saint Dymphna on our behalf. Grant to those we have particularly recommended patience in their sufferings and resignation to Your Divine Will. Fill them with hope and, if it is according to Your Divine Plan, bestow upon them the cure they so earnestly desire. Grant this through Christ Our Lord. Amen.
 

Dymphna's feast day is May 15.

Saturday, January 16, 2010

The Best Health Care in the World

Rush Limbaugh says that he experienced the world's best health care in the United States of America, and it does not need fixing.  I am glad for Rush that he was staying at a resort near a world class hospital for coronary care last month.  I imagine he has insurance to pay for the hotel-like accommodations, the angiogram and several other tests that failed to find the cause of his chest pains.

Given his public platform and his wide influence on American opinion and public policy, I wish Rush would expand his experience of health care in the United States of America.  He could shadow Craig Rennebohm for a few days to find out how health care works for other people.  Craig is the pastor of Pilgrim Church (UCC) in Seattle and, as part of their ministry, "companions" persons who are homeless and mentally ill.  With David Paul, Craig describes their quite different experiences in Souls in the Hands of a Tender God: Stories of the Search for Home and Healing on the Streets.

The emergency personnel got Rush to the emergency room like that [snap!That's not what happened to Sterling.  Over months Craig built the trust of this man who camped in the church courtyard, surrounding himself with trash to protect himself from the evil spirits.  Finally, when the trash included highly combustible materials, Craig convinced him to go to the hospital.  Winter was coming.  The mental health professionals (MHPs) who showed up said they couldn't take Sterling in, because he was a voluntary patient.  They only picked up involuntary patients.  Sterling accused Craig of betraying him and fled the scene.  Craig couldn't find him until a month later, when he read of a homeless John Doe who died of exposure.

Rush was examined for days after they already knew he was not having a heart attack.  That's not what happened to Shelly, seven months pregnant, with bronchitis and in a state of euphoria and grandiosity.  Craig brought her to the ER.  But she wasn't a "good faith" voluntary patient.  They believed she would check herself out so she could go "accomplish her mission."  She didn't qualify for involuntary admission, because she wasn't a danger to herself or others.  What about her baby?  What about her bronchitis?  "Bring her back when she develops pneumonia."

Karl's story is the clearest example of how health care in the United States of America is not working just fine.  Karl is a vet.  He was arrested for resisting arrest for vagrancy.  He just remembers being attacked, and later that the people in prison were poisoning him.  He was transferred to the hospital for two years, then back to jail to be released, no money, no meds, nothing but the clothes on his back.

Craig had been alerted.  He was a total stranger when he met Karl at the jail that morning and took him to breakfast.  Karl was stymied by the question, "White or whole wheat?"  They continued to a clinic, where Karl couldn't understand or fill out the two-page form.  Since he wasn't in immediate danger, they sent him to the Department of Social and Health Services to apply for SSI.  Craig helped him with the six-page form there.  The social worker discovered he once received benefits.  So he had to get a statement from Social Security.  Social Security noticed he was receiving veterans benefits.  Next stop, the Veteran's Administration.  But the counselor there said they were a PTSD program and didn't take walk-ins.  He sent them a mile away to the Federal Building.  His file was in another state, so they had to get it transferred.  Meanwhile, the file was on computer, and said he was getting 50 cents a month, which was going to the hospital. (They could look up the information, but couldn't give him a copy until the file was received in a few days.)  Craig said, "He's homeless and needs medication right now."  So he was sent to the VA hospital, then to the outpatient clinic in the bowels of the hospital.  Several kind strangers helped Craig find the way.  To get help at the outpatient clinic, Karl had to be admitted through ER, where they determined his illness was not service-related.  The waiting list for outpatient treatment was six months, and he might not get in, because he had been hospitalized only once.  The social worker suggested they try the clinic where they had started the day.  By now it was 6:30 and the clinic was closed.  They covered miles that day.  Karl spent the night in a homeless shelter, still not able to remember Craig's name.

That's where I will end the saga, though it is still several days from completion.  Small wonder that 83% of psychiatrists want a national health insurance plan, a higher proportion than any other specialty.  So many of their patients are homeless.

And I thought I was having a hard time.  I have boatloads of people to help, support and advocate for me.  My salary is continued while I fill out applications.  I have a roof over my head and continued health insurance.  Most of all I have Helen, who asked me all the repetitive questions over several days, monitored my capacity, and terminated the work each day, usually after twenty minutes when I was getting overwhelmed.  My phone has been set to mute the disability company whose questions put me over the edge.  She screens my messages.  This process turned me into a pill-popping wreck last fall, and though my memory is not what it used to be, I do know my helper's name.

Rush, the system works well for you.  But not for the rest of us who live in the United States of America.

I commend to your reading Souls in the Hands of a Tender God by Craig Rennebohm with David Paul.  Craig uses his stories to help us see the face of Christ in these abandoned ones, and to frame his theology of God and what it means to be a human being in the sight of God.  We cannot make the journey alone.  None of us.  We are made for life together, made for community.  Those of us blessed with health and wealth may be tempted to forget that.  We may want to believe that we are self-made and assume that we have succeeded through our individual merits alone...  Illness - and especially mental illness - confronts us with the unavoidable truth of our frailty and finitude.  Illness underscores our fundamental dependence on the love and help of others...

Craig describes the work that his community is doing, "companioning" people who are mentally ill.  Companionship can be described in terms of four practices: offering hospitality, walking side by side, listening, and accompaniment.  Let's consider these in detail...

And he tells the astounding story of a very different kind of system in Geel, Belgium.  I will tell you about the miracle of Geel next week.  There is a different way to do this.

The image is from http://mentalhealthchaplain.org

Thursday, January 7, 2010

Spiritual Practices for the Dark Night -- Forgiveness


Okay -- one more in the spiritual practices series.

But I don't put forgiveness in the same category as thanksgiving and tithing, practices I keep and commend to my readers.  I can't say that I practice forgiveness.  When forgiveness happens, it comes as unbidden as a gracious gift in a time of desperation.

I can't tell you how to forgive.  I never learned.

What I mean by forgiveness goes something like this:  This person has a relationship with me, in which I can expect this person to treat me well, AND this person did me some harm, AND I forgive this person and will carry the burden of not forgiving no longer.

I never learned that kind of forgiveness.  I learned BUT forgiveness:  This person did me some harm, BUT it wasn't that big a deal.  Or:  This person did me harm BUT there were extenuating circumstances.  Or: BUT I just haven't figured out the bigger picture yet.  Or: BUT he/she couldn't help it.  Or: BUT I am the better person, and will let it go.

But the BUTs don't work.  They hide a wound that does not heal.  They disrespect me and how I deserve to be treated.  And they cover with a fig leaf my disrespect for the one who hurt me.

The "I just haven't figured it out yet" thing is especially problematic.  There are certain statements that simply can't be reconciled unless something gives.  In my case, my brain.  Rehearsing and rehearsing the same event, trying to comprehend the incomprehensible, experiencing that pain over and over -- this is called rumination, the bad kind of rumination, perseveration even, my therapist would call it when she was trying to scare me out of it.

There are a jillion studies that demonstrate the harm that rumination causes, depression, PTSD, anxiety, suicidal thinking.  Right now I am reading a review of the literature on Constructive and Unconstructive Repetitive Thought by Edward Watkins.  Oh, the things I do for my readers.  It's long.  I'll tell you more about it later, when I get to the constructive part, because rumination is one of my best subjects.  I am as good at rumination as I am bad at here and now. If there were an Olympic event in rumination, I would be in Vancouver next month.  The real reason I am reading Watkins is to give me ammunition in my continuing internal debate with a former therapist, which, come to think of it, is rumination.  But I am not there yet.

Like forgiveness.  I am not there yet.

But last month there was a blue moon.  The blue moon is the second full moon in any given month.  They don't happen very often.  Usually there is just one. Hence the saying, Once in a blue moon.  So I decided to mark the occasion by doing something I hardly ever do.  I forgave someone.

I think the basic move in forgiveness is dialectical thinking.  Dialectical thinking is fresh in my mind because NAMI's Peer to Peer class includes the concept.  It involves holding two contradictory thoughts in one mind at one time.  Such as, This person has this relationship with me, in which I can expect this person to treat me well, AND This person did me some harm.  I have to stop trying to reconcile these two statements.  Each of them just is.  It just is.  I don't have to do anything about it.  I just let it be.

What I am letting be, of course, is the flawed humanity of people with whom I have relationships.  And, as it turns out, that includes me.

I don't know why God forgives.  God must have had it in mind when we were created, because we were created with such a capacity to screw up.  That's the price tag for the capacity to love.  So the theologians tell me.  Lately I am ever more respectful of what I don't know about God.  Like why God forgives, and how I might ever forgive.

I have another therapist, not the one who tried to scare me out of my rumination.  This one does energy work with me.  The way he explained it, we blink into existence and out and in again several times per second.  Inertia being what it is, we usually are pretty much the same from one instance to another.  But little nudges in the energy field can change the direction ever so slightly, and over time, move us in a healthier direction (or maybe not so healthy, but that wouldn't be on purpose, one would hope.)  I said, That sounds like Process Theology (which I studied in seminary.)  And he agreed.  I asked, I don't have to believe in it for it to work, do I?  (Because believing is pretty hard for me right now.)  And he said I didn't.

I like energy work, because I don't have to do the work.  I could do it last year during a long time when I couldn't talk.  I lie on the table, while some soothing music plays and he waves his hands, or connects one point of my body to another by holding each, or rings a tuning fork, or I don't know what, because my eyes are closed.  He could be playing computer games for all I know.  But I don't think so.

We talk about it after, and sometimes there are interesting connections.  Once in a bad time, while I was lying there, breathing, eyes closed, I thought, "This is a spiritual battle."  I was glad to know that my therapist's name is Michael, an auspicious name for the job.  When he rang the chime that marks the end of the session, the first thing I saw when I opened my eyes was an icon of the Archangel over his desk.  So then he said, "It was very strange.  I felt like I was doing spiritual battle."

This week, the word that came to me over and over was "forgiveness," like a mantra.  And afterward he said that my second chakra is particularly active right now, having to do with assertion of self and self-care.

That's what they say, that forgiveness is what you do for yourself.  You lay your burden down and release yourself from the hold that the other person's action, the past has on you.  It sounds like a great idea.  I do get stuck on how to deal with the consequences while letting go of the cause.  "I forgive" doesn't make mental illness disappear.  But not forgiving sure compounds the pain.  So I am going to try a new affirmation when I breathe.  I have been using, "I am here; this is now."  This year it will be, "It just is; let it go."  I'll see how it goes.

The forgiving I did at the last blue moon seems as fragile as moonlight itself, a gift that I hold very gently.  So I do not recommend forgiveness to you.  It's more like, I hope it for you.  And for me.

photo by Simon Howden, from freedigitalphotos.net

Friday, January 1, 2010

Spiritual Practices for the Dark Night -- Tithing


Yes, I'm serious.  Tithing.

I knew about tithing because I am a Christian.  The concept comes from the Old Testament.  I used to think it was interesting -- from a distance.  Like fasting.  Of course nobody except the legalists actually did it.  Still, I suspected I was missing something.

Then two things happened within two months.  I left the person to whom I had turned over all decisions that mattered.  And I attended a conference about what was called the "Alabama Plan."  We did bible studies about money, about tithing, about abundance and God's promises.  And then we were asked, What is preventing you from claiming God's promises?  I realized my answer was -- nothing.  Nothing prevented me.

So I became a tither.

Now remember the context.  Having just moved out on the chief money maker of the family, my household income had plummeted to 40% of what it had been.  It occurred to me -- this was the perfect time to begin tithing.  Instead of 10% of what I was used to living on, now it would cost me just 4%.  The difference between living on 40% and living on 36% didn't seem like that bit a deal.

I was so excited by my new resolution that I decided to tithe for the previous two months as well.  So I sat down with my checkbook.  That's when the magic happened.

Suddenly, I had $300 to give to whatever cause I wanted.

I had never had $300 to give to whatever cause I wanted.  I was rich!

And I have never looked back.  In the years since, I have purchased honey bees, rabbits, trees, a pig, a llama, a sheep, and this year a goat from the Heifer Project.  I have purchased mosquito nets from UNICEF.  I have fought hate crimes and taught tolerance through the Southern Poverty Law Project.  I am helping secure marriage equality through the Lambda Legal Defense Fund.

My most satisfying sense of wealth was the opportunity to purchase four chlorinaters for $300 a pop.  They provide four villages in Swaziland with clean drinking water.  The last time our diocese sent a team to partner with the Anglican Church there, they sent back word, "One elder welcomed us with great thanks. He said, 'Ever since you came, we have not buried a child.'  It's a much bigger project than my contribution.  Now the Swazis are making the chlorinaters themselves.

And I have given lots of money to old churches in small towns.  I make no apologies for paying heating bills of drafty old buildings.  "Hearts starve as well as bodies; Give us bread, but give us roses."  In out of the way places, stained glass windows are the only art most people see.  So I am glad to support the furnace repairs of my church home.  We are family.  Paying the bills is part of belonging.

I couldn't do all this if I hadn't made a commitment -- 10% on the first line item of my budget.  If I had to decide each month whether I could afford it, well, of course there are other things I "need."  But with that money already allotted, my only decision is where I get to spend it.  Frankly, it's almost the only discretionary money I have.  That there is so much of it makes me feel rich.

And what on earth does this have to do with Prozac Monologues: reflections and research on the mind, the brain, depression and society?  This:

Regarding depression: those of us with mental illness experience loss piled on loss, often including financial loss.  We live in a world so programmed for consumption that it consumes us.  We are surrounded by images of things we don't have.  It hurts to feel poor.

Regarding society: the "Crazy Delusion" consumes all the rest of us, as well.  Do you realize that of the almost 7,000,000,000 people on the planet, most of them do not have cable?

Regarding the mind: think of tithing as Cognitive Behavioral Therapy.  First, pay attention to your feelings about money.  Money is the quickest way into what we value.  Examine the assumptions behind your feelings.  Challenge your assumptions.  Do they have a basis in reality?  Explore and test options.

Nothing has ever matched the rush I got when I wrote those first checks.  If you have to be careful about mania triggers, you might start slower.  Figure out what you gave away last year.  Calculate the percentage.  Double it this year, and double it again next year, until you reach your goal.  The trick is to make it a line item in your budget, as intentional as your light bill.

Tithing is a spiritual practice for the dark night, a way to push back your feelings of loss and your anxiety about the future.  I am not going to promise that you will be rewarded by an unexpected windfall.  Rather, it will occur to you that you already have enough.

So like thankfulness, tithing is a form of mindfulness, paying attention.  The Torah has given us this great gift.  Claim it.  As Moses said, Choose life.

P.S.  I seem to have given a lot of advice lately.  Too much.  There will be no third spiritual practice; the series ends here.

Photo by Salvatore Vuono from freedigitalphotos.net