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Personalized Family Birthstone Bracelet – A Meaningful Keepsake

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GRATITUDE-
Practicing an Attitude of Gratitude.
Finding your way home through poetry of ancient wisdom.

KEY POINTS-
Gratitude requires more than a mere "thank you." It requires practical reciprocity.
The role of gratitude in recovery from addiction exemplifies the importance of giving back.
Gratitude for the gifts given by nature requires stewardship of the earth.
Gratitude begins as an idea, advances to practical action, and culminates in revising our identity and relationship to the earth.

Recovery from addiction, as well as from a wide variety of health issues and traumas, naturally fosters feelings of gratitude. But even deep gratitude tends to fade as we turn to the mundane tasks of daily life. People in recovery through the Twelve Steps are aware that maintaining an “attitude of gratitude” is important for remaining sober. Although the word “gratitude” does not appear in the Twelve Steps, Step Three involves a decision to receive the gift of caring and Step Twelve closes the loop by encouraging returning this gift to others in need.

The reciprocity of receiving and giving back is the essence of practicing gratitude. This reciprocity is beautifully described in Braiding Sweetgrass, by the Native American botanist and ecologist Robin Wall Kimmerer[i]. Her poetic writing combines ancient stories from different Anishinaabe tribes with a detailed scientific understanding of how the world of plants feeds and is nurtured by their mother earth. All living beings are treated as persons in the way humans see each other.

Wolves, nuthatches, and bees are all seen as people with homes and children. Humans are only one of many peoples, and all ultimately depend on plants as the sole life form capable of making food from sun, air, and water. In the process, plants feed oxygen into the air for all animals to breathe. Kimmerer’s perspective embeds humans in the vibrant web of life born from our earth. We are wholly dependent on the health of this web. Our own health and existence depend on the health and existence of this web, and yet we have fallen into unawareness of this relationship.

Instead, we expropriated the role of master, turning all the gifts earth freely gives as mere commodities to be monetized. We live in an illusion of our mastery as we graze through grocery stores casually grabbing bits and pieces of plant and animal lives wrapped in Styrofoam and plastic (themselves products of ancient plants pressed into petroleum deposits). We act like children who sneak into our grandmother’s kitchen to steal all the cookies she baked unbidden for us, carelessly breaking the plate that held them.

There is no reason we would be able to recover from the brain changes caused by addiction, but sobriety is a freely available gift. So too is the air we breathe, clear water from natural springs, fruits, nuts, roots, and grains given to us by the earth. No human can invent and produce such gifts. Humans are newcomers on earth, wholly dependent on its freely given bounty. Gratitude begins with becoming fully aware of our dependence on these gifts. Like recovering alcoholics and other drug addicts, we need to “make a decision” to embrace the reality of our dependence on the natural world. We cannot exist outside nature.

Awareness is necessary, but not sufficient, for the fulsome practice of gratitude. There must also be reciprocity. We cannot take from the earth with only a mere “thank you” in return. We must also become active stewards by caring for the natural world that already cares for us. We must enter into a mutual relationship with earth. It is our home, and homes need maintenance and care. The embrace earth gives us must be returned by our embrace of the earth, just as recovery from addiction is maintained by carrying the message of sobriety to those still in need.

The earth is in need. It needs us to take our foot off the accelerator that is driving climate change. As Kimmerer points out, the maple trees that offer us such sweet syrup are needing to migrate further north, becoming refugees from their current home because climate warming is ruining their current homeland. We need to stop driving carbon into the atmosphere and begin nurturing plants that pull it back out of our air.

I have been thrown into turmoil over what I can personally do to practice gratitude for all earth has given me throughout my 78 years. Too blind now even to garden, how can I practice gratitude? What practical action is available? After some thought, I have made a decision to serve the songbirds I remember being so plentiful when I was young but have become so much rarer now. As a child I remember the golden finches, redwing blackbirds, Baltimore orioles, and bobwhites that sang through the woods. Without much vision now, I delight in the birds still chirping in my yard. I am installing a bath to give them water through the dry summer, feeders to invite them to dinner, and small houses to raise their children. I love these birds, so it is time to do something so they will love me back.

An attitude of gratitude starts small but leads to radical shifts in our relationship to the entirety of earth’s natural world if we practice reciprocity. It can lead to seeing the land surrounding us as our home, not as property we own. In Kimmerer’s words, those who immigrated to America must find a way to become indigenous to this land. We need to find our proper place in the web this land has spun. Receiving and giving are two sides of belonging

Kama Muta: Being Moved by Love.
New insights from science about an emotion that’s as old as time.
Reviewed by Kaja Perina

KEY POINTS-
Kama muta is a term derived from Sanskrit that means moved by love.
Experiencing kama muta inspires people to be compassionate, loving and connected.
When love becomes suddenly intense or salient to us, it can give rise to kama muta.
Kindness from others and even compassion towards yourself can make you feel kama muta.
“Sometimes I think,
I need a spare heart to feel
all the things I feel.”
— Sanober Khan

Watching a mama chimpanzee reunite with her newborn after a traumatic birth can leave humans with hearts cracked open, eyes blurry with tears, skin covered with goosebumps, and insides tangled with hard-to-identify emotions. Is it sheer relief of seeing the mother clutch her alive, cooing baby to her chest? Is it vicarious joy? Empathy? Agony for what could have been?

It’s kama muta.
Researchers at the University of Oslo’s Kama Muta Lab define kama muta as “the sudden feeling of oneness, love, belonging, or union with an individual person, a family, a team, a nation, nature, the cosmos, God or a kitten.” There’s a lot to uncover about an emotion that’s as old as time and, yet, one that’s only now being put under the microscope of science. To begin with – its name.

“We could have called it Emotion Z or Emotion 76,” says Alan Fiske, UCLA professor of psychological anthropology and one of the co-leaders of the lab. “But that’s not very elegant.” Wishing to avoid the “baggage” associated with vernacular terms, they turned to a dead language, Sanskrit.

Kama in Sanskrit is love, muta is moved. Kama muta – moved by love.
It remains a mystery to scientists like Fiske why our languages don’t always capture the richness of our experiences and why they don’t more precisely pay tribute to this universal emotion. Fortunately, even without the help of phonemes and syntax, humans will always continue being moved by love. So, next time your heart momentarily stretches wider than you imagined possible, rejoice in the belonging. In Mary Oliver’s words, the world could be “announcing your place in the family of things.”

Here’s Alan Fiske on kama muta.
MP: What is one of your most surprising insights from your research on emotions?

AF: Most people assume that humans are able to clearly distinguish their emotions and have names for every emotion they feel. But that’s not true. I’m now persuaded that the taxonomies provided by language don’t correspond well to the actual experiences that people have. In other words, our names for our emotions don’t necessarily map onto our emotions. We might use one word, like jealousy, to refer to multiple kinds of emotional experiences. Or, we might use different words to describe the same experience.

The term kama muta delineates a distinct emotion that people call by different names in different situations. In English, you might call kama muta the feeling of team spirit when your team is winning, feeling patriotic, love towards God, or even cute kittens. It wouldn’t occur to people that they are talking about the same emotion, because the contexts are vastly different.

MP: How can we tell that we are experiencing kama muta?

AF: Kama muta has a distinct subjective profile in terms of feelings and physiology. To know whether someone is experiencing kama muta, you could inquire:

Are you feeling positive? (for example, Are you happy to have this experience? Would you want to have it again?)
Do you have moist eyes?
Do you have goosebumps or chills?
Are you choked up (have a lump in your throat)?
Are you experiencing a warm feeling in the left side of your chest?
These are common sensations of kama muta. Yet, they are not invariant; people don’t always feel all of these sensations. Kama muta is also characterized by caring, affectionate motives such as wanting to hug somebody, to protect and nurture, to hold the little animal and take care of it, to call their grandmother and say how much they love her. In other words, experiencing kama muta inspires people to be compassionate, loving and connected. In technical terms, people feel motivated to nurture existing communal relationships. Kama muta can also open people to new communal relationships. The emotion itself may only last a few seconds. But the motivation that emerges could endure for minutes, days, or even years.

While kama muta is experienced as a positive emotion, the larger context where it occurs can be positive, neutral or negative. For example, attending my mother’s memorial service was very sad. But when people stood up to express how much they loved my mother, I felt this positive emotion of kama muta.

MP: What is the evolutionary purpose of kama muta?
AF: While we don’t know for certain, we hypothesize that kama muta evolved as part of a specifically mammalian adaptation. Mammals give birth to small and vulnerable offspring. Since their newborns can die of cold or hunger quickly and are vulnerable to predators, they need to be protected, kept warm, safe, and fed. Hence, mammal mothers must be willing to sacrifice their needs and put their offspring first. I believe, herein lie the deep phylogenetic roots of kama muta: this emotion grew out of maternal love, which has to be instantaneous and strong enough to overcome all other motives. As humans evolved, we honed the capacity to feel this emotion not only towards our babies, but towards others near and far, animals, divinity, our nations, even music and the arts.

MP: How is kama muta related to love?

AF: When love becomes suddenly intense or salient to us, we feel kama muta. It’s not how much I love my grandsons, but how much my attention is drawn to that love, for example, when they climb into my lap. Love is a vernacular term. In technical terms, kama muta occurs when communal sharing relationships suddenly intensify. By intensify we mean when we become more aware of the communal sharing or when such relationships are created anew. For example, when a stranger is kind to me and looks out for me, I might feel kama muta.

MP: What are some of the necessary ingredients that give rise to this emotion?

AF: Kama muta can emerge from various perspectives. If a stranger or a friend is suddenly kind to me, I can feel kama muta. We’d call this second person kama muta: somebody else does something that makes the connection salient. I can also feel kama muta when I see a sleeping baby and my heart goes out to it. This is first person kama muta: the feeling is coming out of me. There’s also third person kama muta, which is when you see a soldier coming home to her family and her dog joyously jumping into her arms. Thus, you can get this emotion when somebody shows love to you or to someone else – including strangers or fictional characters.

Moreover, we can feel this emotion through mindful self-compassion. For example, if you’ve been harsh with yourself, and then you’re able to overcome that and feel caring about yourself – perhaps even wish to give yourself a hug – this self-compassion can make you feel reflective kama muta.

MP: How would it help us to know about kama muta and in general, to understand our emotions better?

AF: Having a concept of kama muta enriches our lives because it enables us to recognize it, communicate it, and subsequently to cherish and remember it more. There’s a recursive effect: when I feel kama muta and tell you about it, you’re likely to feel it from hearing my story. While before I wouldn’t have paid any attention to it, now when I begin to feel kama muta, I stop and savor the experience. Oftentimes, this is what artists try to convey with their creations. Having a concept of kama muta helps them express it better.

Knowledge can also be validating. It’s nice to know that when we feel touched to tears by something we witness, it’s a universal experience shared by all humans. Without this knowledge, we might have rejected or ignored our feelings. It’s meaningful for people to know that what they have been experiencing is real. And that there’s a word for that.

Many thanks to Alan Fiske for his time and insights. Professor Fiske is a psychological anthropologist at UCLA and at the Kama Muta Lab at the University of Oslo. His books include Kama Muta: Discovering the Connecting Emotion.

BURNOUT-
Match Day and Mental Health.
Personal Perspective: Preventing burnout in medical school.
Reviewed by Kaja Perina

KEY POINTS-
March 17 is national Match Day: an important day for reflecting on medical school.
Doctors have some of the highest rates of work dissatisfaction and suicide.
Many factors that contribute to physician burnout begin in medical school with 11% of students contemplating suicide.
Exploring medical school experiences can help identify how to work upstream to prevent physician burnout and improve mental health.
March 17 is Match Day in the US. At exactly 12:00 pm EST, medical students all over the country, including myself, will be handed an envelope enclosing our fate: the residency program where we matched and will train for the next three to seven years, depending on specialty. For many of us (and our support networks), this is the most momentous day of our lives— a culmination of innumerable sacrifices and hours of studying. But as I look forward to a career in psychiatry, I can’t help but look back at the mountain we traversed and think about how our experiences have shaped our psyches.

Compared to other professions, doctors have some of the highest rates of work dissatisfaction and suicide; around 300 physicians die by suicide each year.1 What I find particularly shocking is that this shift begins in medical school as we become immersed in the intense, often unforgiving culture. Upon entering medical school, studies find that medical students experience lower rates of depression compared with age- and education-matched peers. Yet, during medical school, the prevalence of depression jumps. Almost 30% of students report suffering from depression or depressive symptoms at some time during medical school, and 11% of students contemplate suicide.2 A confluence of factors contributes to these acute changes: the sheer volume of work, lack of sleep, stress from continuous high-stakes examinations, isolation due to academic demands, fears about future capability, feelings of inadequacy, and a non-supportive work environment.3

Emotional and physical crises don’t happen on your timeline.
This past year, I was rotating on internal medicine, providing care for patients with acute hypoxia and congestive heart failure. Meanwhile, on a medicine floor just like mine across the continent, one of my grandmothers died of respiratory failure while the other was hospitalized with a failing heart. Each day, I saw them in the patients I cared for—my grief unexpectedly bubbling up. In medical school, I’ve had three family members pass away and a few health issues, some of these occurring dangerously close to critical exams. The administrators were supportive but could only offer me the option of pushing through or taking the entire year off (one week off meant too many missed requirements).

Medical school has an unceasing deluge of tasks unkind to the unpredictability of life and healing. Through this, I’ve learned the importance of being in conversation with myself to assess (and reassess) my capacity to carry on or my need for time off. I’ve found it similarly essential to communicate with faculty and access support resources to process difficult emotions and prevent compounding them, which can create fertile ground for future burnout.

Emotions and self-worth inevitably become intertwined with our professional roles.
As a third-year student on my surgical rotation, the attending urologist began grilling me on the embryological development of the testes. When I blanked, he would not let up with his questions. He emphatically punctuated the diatribe with, “even a preschooler would have more knowledge than you.” For the rest of the week, my gaze was locked on the floor. I turned inward, questioning my self-worth and whether I deserved to be in medicine.

What that physician said to me was unacceptable: everyone deserves psychological safety in their workplace. When discussing the problematic behavior of senior physicians, one of my classmates said, “**** rolls downhill.” Perhaps, but that does not mean we should have to sit at the bottom and eat it. Improving mental health in medicine requires addressing people who sustain (historically) toxic work environments. In addition to changing this culture, personal reflection can help disentangle our worth from our white coats.

At my core, I know I am a good friend, partner, and person, but these transcendent feelings sometimes become hard to remember. To spend as much time in the hospital/library and sacrifice as much as we do — time, money, relationships, sleep, mental health — means that the line between job and personhood becomes blurred. Cognitive distortions often form and are exacerbated by society convincing us our profession is a “calling.” Given this, it is invaluable to find time for the activities and people that remind us of our identity outside of medicine to re-calibrate our self-worth.

Solidarity can and should take many forms.
“You’re going to meet all your best friends in medical school,” I listened expectantly to my dad (a doctor), as we drove to the airport before year-one orientation. It didn’t take me long to realize that immediate, sorority-like friendship is not everyone's reality. However, after four years, I can attest that a closeness does develop with classmates. This bond was not immediately obvious to me, and it didn’t come from expertly navigating medical school’s new social norms and high-school-like cliques.

I feel this solidarity as I hurry down the hospital hallways and lock eyes with another fourth-year student. We nod to each other with understanding eyes. This bondedness developed through the unspeakable amount we’ve jointly experienced: from innumerable lectures/exams to difficult rotations where we endured doctors with the emotional intelligence of sea sponges, fluid-filled nights on OB/GYN, or the heat of multi-hour skin grafts on burn victims where they keep the operating room hot. Our closeness is less High School Musical and more Lord of the Flies.

Not everyone’s journey is the same.
Although medical school is notoriously demanding, such demands are shaped by intersectionality and not necessarily borne equally. At my White Coat Ceremony, over a third of students received their white coats from a family member already in medicine– a revolving door of privilege. Medicine has historically been (and remains) a white and high-income space.4,5 Despite more individuals from underrepresented backgrounds entering medical school today, the environments that students arrive to learn in have largely stayed the same. The necessary anti-racist institutional culture, financial resources, mental health support, and representative mentorship that allow students to feel supported are not yet robust.

This cultural disconnect is consequential: one study of medical students found that increased microaggression frequency from colleagues and senior physicians was associated with a positive depression screen in a dose-response relationship.6 The Association of American Medical Colleges (AAMC) is working to increase the number of students underrepresented in medicine. But the goal cannot merely be representation, rather it should be to create a new culture and system where students can thrive. The floor needs to be open for students to describe their experiences while institutions work to address systems that impact their mental health and potential.

It is hard to pause and look back when constantly moving forward.
I remember the shell I became and the neuroticism that set in while studying for the US medical licensing exams (USMLE). For weeks, I sat studying for 15 hours a day, not leaving my apartment, and attempting to sleep while gripped by the stress of my exam score determining my ability to match into the specialty of my choice. After completing our first USMLE (Step 1), my classmates and I were ecstatic, scrambling to organize parties to celebrate before our fast-approaching clinical rotations.

I’ve taken over 400 exams since starting college and, somehow, it hasn’t become less stressful. The stakes have only felt higher as the sunk cost and bearing on my professional future grows. And as the competition for medical school and residency increases, a student must not only have impeccable grades but also be a renaissance person (do ground-breaking research, start a non-profit organization, climb Mount Everest, found a start-up, win a Nobel Prize, etc.); expert extrovert (winning over each resident, doctor, interviewer evaluating us); and world-renowned used car salesman (packaging oneself in countless application essays and interviews). Then, once you finally get into medical school or match into your dream residency or fellowship, they tell you to relax and enjoy it. How is a person whose cortisol and productivity have been running at such a high-octane level supposed to simply chill?

It’s hard to flip the switch into Zen mode– it takes time for our bodies to let go of cumulative stress. Yet, the demands in medicine never stop, and the habits we convince ourselves are temporary often carry over. Unlearning conditioned behaviors is hard, making it vital to learn how to pause (guilt-free) despite the inundation of to-dos early in our careers.

Understanding mental health on an intellectual level is different from questioning its applicability to oneself.
Although physician suicide is the most acute and devastating issue surrounding mental health in medicine, the downstream impacts of medicine’s high stress and isolation are much more expansive. Students around me have struggled with anxiety, eating disorders, exercise addictions, and substance use.

As medical institutions address the external factors contributing to trainees' mental health challenges, students should also feel empowered and accountable to lend and seek help– dismantling stigma in the process. When we think about physician burnout, we must work upstream and broaden our conceptualization of mental health risk factors and what struggling looks like (a student can still score in the top percentile on exams). We can all play a part in preventing physician burnout by creating a culture of reflexivity, support, and accountability– and joining together to advocate for more robust mental health resources and workplace protections.

SUICIDE-
The Fundamental Unpredictability of Suicide.
No one can predict which individuals might die by suicide.
Reviewed by Vanessa Lancaster

KEY POINTS-
We can assess suicide risk but not predict whether any individual will die by suicide.
Over 50 percent of those who die by suicide do not have a known mental health condition.
Losing a loved one is always painful, but guilt complicates the grief that follows a suicide.

Recently a friend said, “My partner is threatening suicide. How can I know if he’s serious, manipulating me, or crying for help?” I responded that even seasoned mental health professionals want to know the answer.

I didn’t learn of my grandfather’s suicide until 20 years after it happened, even though we lived with him when he died. For many years, our family wondered, “How could we have predicted this to have gotten him some help?”

In over 50 years of practicing psychiatry, every patient who has died by suicide has surprised me. After each death, I asked myself, “Should I have known? Could I have prevented this?” These are the same questions their surviving loved ones ask me as they deal with the grief that is complicated by feelings of guilt.

Suicide is rising in the United States, with a 33 percent increase since the beginning of 2023. The greatest increase has been in those over the age of 45. Of those who died, over 50 percent did not have an identified mental health condition. But a retrospective review of those suicides found that 90 percent of those who died had a mental illness, often associated with alcohol or drug abuse.1

How good is anyone at predicting anyone who will attempt or complete suicide? Determining suicide risk is complex.

What causes someone to consider suicide?
I believe when someone dies by suicide, that person feels hopeless and helpless. They believed nothing would ever change, and no one could help. They often don’t reach out to anyone because they believe it wouldn’t matter if they did. They think, "Why would I reach out; it won't matter if I do."

For some, this represents a life-long struggle with those feelings. For many others, a volcano of those feelings erupts suddenly.

The explanation can be divided into long-term or imminent causes.

Long-term causes include:
Chronic mental illness
Genetics, likely with many genetic variants
Personality type, especially impulsive and aggressive
Early trauma

Imminent causes include:
Mental illness–Acute onset
Physical illness
Crisis, e.g., shame and humiliation
Alcohol and substance use
Availability of firearms2
Exposure to the suicide of a loved one
Predicament–Being forced to choose between two undesirable options
As with my grandfather, in most cases, no single cause or stressor leads to suicide. Our family has a history of depression. But my grandmother's death and a visit to Germany after WWII were the precipitating factors.

Assessing the Risks
The Patient Health Questionnaire (PHQ) is a tool used in primary care settings. It screens for the presence and severity of depression, anxiety, and alcohol abuse. Other disorders are also suggested. The ninth question (PHQ-9) addresses suicide. It asks, "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?"

Lifeline Public Access
To assess suicide risk, the PHQ-9 is often combined with other self-assessment scales. A commonly used one is the Columbia-Suicide Severity Rating Scale (C-SSRS).

These tools help identify those at high risk. But if a scale is too sensitive, it will capture all those at risk. This may lead to overly restrictive management, e.g., involuntary hospitalization. An experienced, well-trained mental health professional needs to interview those at risk.

That interview will Include the following:
An evaluation of the risk factors
A search for protective factors
The best interest of the individual
Collateral information from loved ones
Clinical judgment
Protective factors include the ability to cope with stress, religious beliefs, and frustration tolerance. They help define those at lower risk. But research on protective factors is sparse. Even when protective factors are present, they may not counteract significant risk.

Assessment is not a prediction.
Assessment of risk can determine who is at risk for suicide. But it cannot predict which individual will die by suicide. Assessment tools depend upon the notable unreliability of self-reporting.

Some have claimed that these assessment tools are only slightly better than chance. A recent study concluded: There is no standard of care for predicting whether an individual will die by suicide."3

Suicide affects everyone.
A person who decides to die by suicide believes they have made a rational decision. They usually believe their life is toxic to others and the ones who love them would be better off without them. Their distorted rationalization is: Of course, it will hurt them, but they’ll get over it. I will hurt them even more than my death by continuing to live.

Families and loved ones do not share that belief. Rapt with guilt, they wonder, “Should I have seen this coming? Why didn’t I listen?” In the event of a suicide, trained and experienced mental health providers ask these same questions. But there are limitations to our clinical judgment, and the tools we have available perform poorly.

What could I have done?
When those who’ve lost a loved one from suicide ask, “What could I have done?” the painful answer is, “It is likely, there is nothing you could have done.” Because of impulsivity and poor judgment, people who only threaten suicide to manipulate others die by suicide.

My family struggled for years with guilt about not intervening in my grandfather’s death. But there was nothing we could have done to prevent it.

Sometimes, only a person's behavior suggests they are very depressed and may think of suicide. If you are concerned, ask your partner or loved one, “Have you been thinking you’d be better off dead or hurting yourself?” They may welcome your question.

No harm comes from asking about suicide.
Perhaps the most important thing to do is to offer hope: “I believe you don’t have to feel this way. I believe that someone can help.” If you receive the threat, share that information with someone. Don’t try to handle it alone.

Each threat of suicide must be taken seriously. If your partner truly wishes to die and has a plan and intention to follow through, get immediate help.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7, dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741.