Legs To Stand On: A Psychological Journey
The journey from diagnosis of hip problems to total hip replacement (THR) surgery is an emotionally difficult one, especially for dancers and athletes.
Just as she was starting to confront the inevitability of her own surgery. I prevailed on my gym-buddy, Lois Meredith, PhD., a practicing psychotherapist, to write about her psychological decision-making experience She is scheduled for her bilateral THR surgery on March 23, 2004.
Dr. Meredith danced seriously as a young person before turning to theater. After graduate school she taught theater and psychology at Oberlin College. Currently she is a clinician, consultant, and playwright with a private practice in New York City. She serves on the faculties of a number of training institutes including the Gestalt Institute of Cleveland.
I fervently wish I had had this intimate and insightful recollecting to read when I was facing my own surgery. I recognize so much of my own process in hers. -NR
Part I: Moving Towards Surgery
I first had inkling that something was wrong about five years ago after a particularly strenuous workout at the gym: a sharp pain in my left hip. Those of you who are athletes, actors, or dancers will understand that pain is a professional badge: if you're not hurting somewhere you're not really doing it! Eventually, the sharp pain went away and I was aware of soreness only when I "overdid": hiked more than ten miles over rough terrain, or practiced my new favorite pastime: roller blading. (I had stopped long distance running -on paved surfaces, I'm ashamed to admit - several years before. Old dance injuries in my knees had begun to bother me. ) A year or so later, a bad fall onto my right side while blading resulted in an aching right hip. In order to stay away from my right hip as much as possible I began to favor my left hip. It wasn't long before my left hip started to hurt again. It finally occurred to me that I should consult a physician.
I am, and have been for as long as I can remember, my body.. It's not just about looks, though I don't want to minimize the importance of appearance. It's nice to be slender and "cut". Among other things clothes look better on you. No question. More importantly though, I have been the way my body worked: My body expressed me. It was the carefully honed instrument of my thoughts and feelings. Dancing, I could be provocative or sexy or athletic. Speaking before an audience, an erect stance allowed my voice to be powerfully projected. In the consulting room staying in touch with my body and my breathing allowed me to be "centered," even in difficult patient interactions. It was a self-perpetuating cycle: my body did my bidding and the fact of my physical engagement reflected back to me who I was in the world. Proprioception. Every time I extended a foot to take a step my nerves and muscles reminded me that I was strong, capable, energetic. And although we all have our bad moments, most of the time I felt that, if push came to shove I could take on most of what the world sent my way. My body and I were in this together. It did me proud. In the trade, we call this healthy or functional narcissism (as opposed to pathological narcissism).
I had started dancing as a kid: ballet, later modern dance.
I was in the modern dance companies both in high school and college. Later I was approached by Louis Falco's company to apprentice, but I choose to go graduate school instead of dancing professionally. With my newly acquired PhD I began to teach at Oberlin. There I became a member of a theatre company directed by Herbert Blau, former Artistic Director of Lincoln Center. Herb was interested in a form of theatre developed by Jerzy Growtowski in Poland:"psycho-physical' theatre. It made the body and it's expressiveness as important to the creating of character (and thus, plot) as what was on the written page. Character was what the body experiences and expresses. Our training as actors therefore involved tumbling, gymnastics, mime, and the T'ai Chi - in addition to physical improvisations, work on voice, and the interpretation of texts. Back to the body. I felt right at home...
Lois in her one woman show "Faces of Woman"
A year or two later, and in keeping with my growing conviction that personality and body are inseparable, I began the Post Graduate Training Program at the Gestalt Institute of Cleveland. Gestalt therapy is a holistic approach to human feeling, behavior, and change. No part of our functioning can be seen independent of the whole person. Although Gestalt theory and practice incorporates the ideas about body promulgated by Reich and the latter day bioenergec analysts, it is much less invasive and doctrinaire. My mother was on the Institute faculty. Despite the fact that I already had a Ph.D. and had done an internship I was taken into this community of health care professionals as the "house artist," the person who did all that crazy theatre stuff. At the time I was not sure what direction my professional life would take: whether I would embrace holism as an artist or as a clinician. As it turns out, I have done both.
DENY, DENY, DENY
In 2000, on the advice of my primary care physician, I went to see an orthopedic surgeon who took x-rays and informed me that both of my hips showed substantial arthritic degeneration, the result of two factors: all the trauma they'd been subjected to and a history of osteoarthritis in the family. (My father had suffered such bad arthritis in his knees that as a thirty-three year old he received a medical discharge from the Army.) At any rate, the surgeon in question smugly suggested, "When you can't tie your shoe laces any more come back and see me." That was all I had to hear. "Fuck you and the horse you rode in on!" I thought but didn't say. I left his office vowing that he would never get his knife on ME! Not only had he been arrogant and insulting, he had suggested that I couldn't beat this on my own. I'd show him!
If you're hell bent on denial. You'll use just about anything.
I continued to roller blade (falling from time to time) studying ballroom dancing with my companion, Allan, and training strenuously. A part of that training involved heavy weight work with my legs. I noticed, (even complained to myself) of, pain in both hips after these workouts. I cut the weight down. Somewhat. Furthermore I was fast losing mobility. My hips felt tight. Not only could I no longer do a full "lotus," I couldn't even manage the sexy, wrap-your-legs-around-the-guy tango moves Allan and I were learning.
But I still would not relent. Much later, when I began to tell people, one friend crowned me, "Lois, Queen of Denial" (Say it out loud. You'll get it!)
One of the first feelings I had when I began to let in that something was really wrong with me was anger. Why was this happening to me after all the work I'd done to keep myself in shape? Had I been too vain? Too arrogant about my capacities and about "cheating the clock"? After my divorce I had picked myself up, found a new home, a new office, a new life with a wonderful man. It had made me feel young, just starting out, instead of the middle-aged person I actually was. Was this some kind of crazy punishment for my hubris?
Of course, I had nowhere to go with this anger. Whom could I blame? I turned the anger against myself.
SHAME AND SELF LOATHING
I must have been responsible for this failure of my body. I shouldn't have trained so hard, shouldn't have run on hard surfaces all those years, shouldn't have pushed through pain all the years I was dancing - particularly shouldn't have started to roller blade in my middle years. I had taken some bad falls: on my hips. I was now paying the rightful price for my folly. The effects of my stupidity were written in my hips. I didn't want anyone to know how dumb I had been.
By the spring of 2003, I had begun to limp, though I concealed it pretty well most of the time by using my feet differently and by "lifting" out of my hip joints when I walked. I was turning into another person and I didn't like her at all. I didn't want anyone to see her. It was quite a cover up. I was just fine, thank you very much.
I was still trying to control how I saw myself (I had brought this upon myself, so I was still in control.) and how other people saw me.
I was full of shame.
IMPOTENCE AND LOSS OF CONTROL
Some events are impossible to ignore. I'll never forget the day my eight-pound cat leapt to my shoulders for our usual turn around the apartment. It was a loving ritual, something we'd been doing since she was a kitten. But on this morning, my left leg could not bear the additional weight. My knee buckled. I almost fell.
And I began to notice other things. I couldn't carry many groceries home from the store. I couldn't carry my overnight suitcase onto the train platform. I could still walk, but the distance I could cover comfortably was diminishing.
I had to admit it: there were things I now could not do.
I began to wonder, when I was in a restaurant, if I could make it to the ladies room. I stopped going out into the waiting room to greet each of my patients. I wondered if they noticed the change, or if they were noticing my limp. (Only one out of 30 or so per week said they did during the entire period preceding my surgery!) and, if so, would they still think me competent to deal with their psychological issues. Quite a projection, I'd say!
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The more debilitated I became, the more anxious I became. I was clearly not in control of my life as I had been before. How could I go on like this? Would I be able to take care of myself? I imagined myself on a walker with a helper of some kind trying to make it down the aisles of Fairway. Like my ninety-three year old neighbor.
Then I began to forget things. I, who had always had near perfect recall! I realize now that so much of my energy was tied up in worrying about myself that not much was left for memory function.
Anxiety becomes an independent disability.
Pain is a funny thing. My pain was not constant - even at the end, thank goodness! - except when I tried to walk. I was not awakened at night by physical pain.. Sitting in my consulting room, or reading the paper, or watching a movie, or having I nice dinner, I forgot for periods of time that I couldn't just get up and go about my business. I would leap up, start across a room, and fall.
When it hurt, though, it really hurt. Sometimes a constant, dull ache, sometimes a sharp pain that took my breath away. Pain was enervating.. And it scared me. When walking I was constantly reminded. "There is something wrong with you. Don't try anything daring. You could fall. You could hurt somebody else. Better wait until that young mother with a stroller and a dog have cleared the curb before you try it" I was worrying about clearing the curb, for God's sake! That wasn't me!
Pain led to more anxiety.
Lois in "Orpheus Descending"
As I hobbled around, still trying to hide my disability most of the time, much of my sense of being an attractive woman, an object of sexual desire left me. So much of my sexuality had been dependent on my ability to move erectly, fluidly, gracefully. I had taken animal pleasure in the functioning of my legs and hips, the feeling of being centered in my walk and connected to the ground I walked on. Walking was one of the first things I commonly worked on with women who wanted to explore sexual issues.
I had always loved clothes. Not that I was a big shopper. But I loved style, the cut of things, the way clothes moved on the body. Without the same body sense I lost interest in dressing stylishly. Towards the end of my pre-surgical period I must have worn the same pair of stretch jeans to the office for weeks. And when all the cashmere went on sale at Ann Taylor after the holidays, I briefly surveyed the stacks of soft, luscious colors and left the store.
I remember studying my standing image in the mirror at the gym. I looked pretty much the same. People still admired my well-developed arms, shoulders, and back, my slim waist, my erect posture. Even my butt still looked pretty good. As long as I didn't try to walk anywhere.
Shaving my legs got to be a problem since I could no longer stand on one leg in the shower. I stopped trying so hard.
Allan continued to relate to me as if I were the same object of desire. I will be eternally grateful for that. It kept me saner than I might have been otherwise. I thought at the time, though, that he was a little nuts to still be interested.
On New Year's Eve, 2003, we had plans to go to dinner at the tennis club in New Haven with our oldest friends. There would be dancing. I put on a long velvet dress and dangling rhinestone earrings. As we walked out the door I thought to myself, the costume is right. Do I still have it together enough as an actress to fill the role?
New Year's Eve not withstanding, my world was getting smaller and smaller. As of January I was still taking the bus to my East side office (cabs were too hard to get in and out of). But each day was a trial. A therapist basically sits all day. I tried to make adjustments by lounging on the side of my desk, by changing chairs. But when I got up at the end of a day, I couldn't walk at all. I stopped having lunch with friends. Allan and I did less and less on the weekends. I measured out the possibility of activities in my mind: "Let's see. I could probably make it to the post office and the bookstore. But the grocery store would then be ten blocks in the opposite direction. I'll have to choose one or the other." Eventually I would lie In bed at night having to urinate but putting off the walk to the bathroom until I couldn't stand it any more.
I cried at the drop of a hat. Appropriately and inappropriately - though never with patients. Having to focus on their lives instead of mine helped a lot. But when I was off duty, I was touchy, bitchy, hard to get along with. I was tired all the time. Everything felt overwhelming.
With poor Allan I was totally self-consumed. I was incapable of letting a day or even a conversation go by without some reference to my physical state or upcoming surgery. I must have been insufferable!
Each day my hips seemed to function less well than the day before. It was happening fast. Now my knees also began to hurt and to buckle under me with some regularity. I began to loose my balance, to stumble. Going down stairs became a real hazard. I clung to the railing like the scared person I was becoming. Preciously I had been told. : " I can't believe these are your x-rays. I don't know how you can be walking so well," Now I had become my x-rays.
Psychoanalysts would say that I had suffered a "narcissistic wound," a blow to the way I saw myself.
But for "body people" it's more than that: I had suffered an assault on the very foundations of my self. "I" no longer existed.
I was in mourning for the person I had been.
It was part of a syndrome I had often diagnosed in other peopIe.
I was depressed.
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PEOPLE WHO HELP ALONG THE WAY
Whatever dramatic things we experience - good or bad - from falling in love, to losing a loved one, to looking for a job, to finding out that we are pregnant, or that there is something wrong with us, we feel and imagine that we are the first person it has ever happened to. I felt totally alone with my disability: ashamed, diminished, and bewildered. Additionally my shame kept me isolated. I tried to hide it, wouldn't talk about it. Until the day Naomi Rabinowitz appeared at the gym with her new hip. I had noticed and admired Naomi before. An elegant dancer/physician, she had moved with grace and purpose. At the barre, she stretched within an inch of her life. A body person.
But I hadn't seen her in a few months. Here she was now, her red hair redefined in natural salt and pepper. She seemed thinner, perhaps a bit pale. The she told me with a little smile: "Two months ago, I got a new left hip." It was as though a cork had been removed from my soul. All the bottled up questions and concerns I hadn't dared to voice. Here was someone I could talk to. And talk I did.
Naomi was the single most important encounter I had in the days preceding surgery I can honestly said she changed my life. She took the shame away. Other people, good people, young people were going through the same thing! No question of mine seemed stupid or silly, She responded knowledgably and humanly. I wasn't alone any more.
She had even created the website on which you are reading my reflections: a wonderful compendium of medical information, post-op possibilities, contacts, and first person recountings. I felt then and feel now that Naomi has done the world an invaluable service: the generosity of her soul made material...
One of the things that had struck me about Naomi's experience was the careful way she had prepared for surgery. Physical therapy was a part of that preparation.. She had worked with Chris Bratton at Westside Dance Physical Therapy. Doing something was maintaining a modicum of control over one's existence. Good!. I called Chris, who, unfortunately was too busy to see me, but who recommended someone wonderful: Michelle Humphry.
My original intention with physical therapy was to avoid surgery as long as possible, but, as my condition worsened and it became clear that surgery was inevitable, I knew I had to develop a post-surgical physical vocabulary. Tiny things that I could begin to do right after surgery.
Michelle, a petite redhead, former professional dancer and diver with incredibly strong hands (and an equally strong will when I was failing) was reassuring. I trusted her. I felt safe with her: When I was full of it, she told me so. She was also more patient with me than I was with myself. She had a plan for me, an arc of preparation that we embarqued upon. She'd seen it all. She knew.
Michelle was and is skilled in the techniques of Joseph Pilates, a former dancer and later dance physical therapist, who developed a system of working with injured dancers based on the notion of core strength. Many of the Pilates exercises involve small concentrated movements originating from the core abdominal muscles and the use of the breath. Stuff you can still do when you can't otherwise move.
I also discovered some interesting little defects that I had been unaware of. My VMOs, the little muscles of the quads that attach on the inside of the knee had become atrophied. They were probably getting inhibitory signals from my hips. That's what was causing my knees to buckle! We worked to strengthen them. And other things: my hips flexors were tight, my lats scrunched, my upper glutes disengaged.
For a body person these discoveries are treasures.
Now I had something new to worry about. O.K. I was going to have to have my hips replaced, but how to choose a surgeon? What was important? Reputation? Fine, but everybody had "the best in town" to tell you about. I began to talk to people who had had the surgery, to research materials, surgical techniques.
One of the problems was that for each person who'd had a good experience with a given surgeon, there was also someone who'd had a not-so-good experience. I began to make appointments to meet some of the most highly regarded. Even though I was incapable, as a non- physician, of discriminating between the efficacies of certain materials (Ceramic? Cross-linked poly? Titanium?) as opposed to others, or between particular surgical techniques (Should I go for the new "experimental" techniques which promised faster healing even though nobody around had done many of these surgeries?). Maybe I'd at least get a sense of whom I felt comfortable with.
1. One surgeon kept me waiting for an hour and a half, I finally had to leave in order to be on time for my own patients. I should have known better, but I agreed to try again the next week. This time he saw me at the appointed hour - but only for ten minutes. And he hadn't been able to find my x-rays, ordered out of the warehouse some five weeks previously.
2. A second surgeon, whose work had been highly praised by people I respected, seemed more interested in lecturing to me than in listening to me. I kept having to interrupt him to get a word in edgewise. Should this matter, I kept asking myself? All that should really matter is his skill as a surgeon. And he's reputed to be particularly attentive during the post-op period. Something I value greatly.
Sometimes we learn what we want to do by observing what we actually do do.
I kept not making a surgery date.
3. The third surgeon, also highly reputed, became a bit sullen when I told him I had seen his colleague. He answered my questions with one-sentence answers. When I asked him if there were something he'd like to tell me, he answered that were he certain I would become his patient, he would spend twenty minutes talking to me of this and that. "Dr, X.," I said sweetly, "the way that you talk to me about 'this and that' will determine whether or not I choose you as my surgeon." He smiled, softened and spent half an hour with me.
I needed someone who could respond to the totality of me: my hips and all the rest.
I watched myself as I followed him into his office and agreed to have him do the surgery on March 23rd.
Seemed like a good date: the day before my birthday.
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The French have an interesting saying: "When you chase fear out the door, it comes back in through the window." I think the message is that anything not fully resolved comes back to haunt you.
I had hoped to feel some relief after choosing a surgeon and setting a date. Some people report that they then look forward to the surgery, even welcome it. This didn't happen to me for quite a while.
Now I was talking optimistically about surgery. Reality testing. Starting to tell my friends and patients and to consider the practical details of what surgery would entail. Looking at the video Naomi had given me was a hard dose of reality. In it, a healthy young woman demonstrated all the positions you couldn't be in for six weeks after surgery. Then she demonstrated how to use crutches and canes. And to put your socks on with a long robotic contraption. I tried not to think about it.
But all the things I tried not to think about caught up with me at night. My sleep is still troubled as of this writing. In my worst wee hour moments - even though intellectually I knew and know better -I was sure that despite the great reputation of my surgeon, something bad would happen with me. Something would go wrong in the surgery. I would have a blood clot that went to my brain, or there would be nerve damage, or a cut muscle that would never heal. Once I let them at me, I would either die on the operating table or survive, but never walk again.
How much would I hurt after surgery? Would the morphine slow down my bodily processes so much that I wouldn't be able to defecate? How would I get to the bathroom after they removed the catheter?
Would I be able to get around sufficiently on my crutches or canes? After all, I had to get back to work. I was telling my patients I'd be back in the office in four weeks.
And my patients, how would they react to my absence and then my incapacity? Patients project all kinds of things on their therapists. Would they be angry with me? Would they feel abandoned? Would they find me unfit to take care of them?
Even if I came through it pretty well, how would the new hips feel? Would they feel like "me"? Would I look the same? What would I be able to do? Would I be able to move the way I once had? Could I go back to ballroom dancing? Bike riding" Roller blading? Weight lifting?
Would I feel sexy?
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As I look back now on the months preceding surgery - and I'm not quite there yet -there aren't a lot of good things that can be said about my physical and mental state. I am becoming more and more incapacitated. Sometimes I feel like an old crone. The depression has lifted. Somewhat Not the anxiety. But I'm starting to see some light.
One thing that helps, though it's irritating in its own way, is all the stuff you have to do to get ready for surgery. It keeps me busy and feeling that because I'm getting things done, I am still in partial control of my existence: get the insurance in place, give blood in case they need it during surgery, get your hair cut and streaked, get a pedicure since you won't be able to reach your toes for six weeks, arrange for post-op care, tell all your patients, etc., etc. The list seems endless. And, of course, I plan to work until the Friday before my surgery.
An unexpected consequence of not being able to count on my legs is that I'm starting to have a sense of perspective. A sense of my own inanity. The absurd. One day you are in charge of things, the next, every time you get out of a chair the unexpected can happen. Occasionally my loss of control is a relief. I marvel at the artificiality of our usual sense of mastery over events, of the notion of purposeful action. The first day I tried to use my cane outside on the street, I was quite inept. I was walking less well with the cane that without it. What a klutz! I started to laugh. A liberating, heartfelt laugh.
Using a cane also began to liberate me from the old notion of how I saw myself. When Allan, months previously, had gently offered me a cane he had from a previous injury, I scoffed at the idea. Using a cane was "ego dystonic," it was "not me". It was not a "me" I ever wanted to be. Later, since I had to use a cane anyhow for balance, I was willing to explore the dimensions of myself as cane user. I even came to enjoy experimenting with the good luck cane Naomi had lent me. Now when I passed someone on the street who is also using a cane I meet their eyes and ask" How are we doing?" Almost universally I am rewarded with a look of gratitude - and sometimes with a whole story.
Patience with myself is another trait that has been in short supply in my personality, Strangely, I am normally quite patient with other people, conscious of their needs for support and encouragement. But this didn't extend to me. In the weeks preceding surgery it has become a question of either being more patient with myself or decompensating. I have been forced to become much less demanding and critical of myself. O.K., so I didn't get this or that done. So I forgot to pick up my dry cleaning three days in a row, so I can't stand long enough to prepare a really nice meal or do my usual routine at the gym. So what? I'm becoming a bit gentler with myself. Nicer. I expect less of myself and enjoy things more. After all, there are a lot of things I can still do.
At the gym, for example, I am lifting less weight - but I'm lifting. And, who would have thought, I can still do the elliptical cross trainer! Have to: I'm in training for surgery!
I've become less afraid of letting other people help me. Not a lot. I suspect that will come later. But a little. Taking care of other people has been such an important part of my identity.
At home I've stopped leaping up to clear the table, stopped insisting that I am in charge. I let Allan go to the grocery store with me and even carry things.
In the subway, people sometimes take my elbow and offer me a seat! I smile sweetly and accept. Could I get into this?
I remember the day one good friend, Susan, left twenty Bextra (an anti inflammatory medication) with my doorman from her own supply. I felt loved instead of patronized. I feel the same about the regular visits of my friend Zohra to keep Ena (my cat) company on my long office days. And about friends like Veronika who call more frequently to get a supportive read on my emotional state. And about Naomi's endless patience in responding to my worried questioning.
At the gym a lady I don't know at all, but who'd heard I was going to have my hips replaced, rushed up to me today to tell me that she'd seen a program on television in which a professional ice skater was interviewed about his hip replacement: "And he was leaping, way up, and coming down so gracefully.!" It was her optimistic offering to me. I was touched to the point of tears
The flip side of moving so slowly now is that I have time to look at things. My mother, an artist as well as psychologist, took me for a walk when I was a little girl. "What do you see?' she asked one day as we crossed the street. "A curb," I said. "Look again. Do you see that under the curb is the shadow of the curb?" I'm seeing shadows and shapes and colors and textures and faces. Not that I was oblivious before, but something new is going on.
To combat my anxiety I've adopted a relaxation exercise that I use with patients. I've never been good at meditation. Too cerebral. Emptying the mind is an idea about ideas. Since anxiety is a bodily event, why not use the body? The exercise involves slow inhales and exhales to progressively longer counts as I concentrate on relaxing the long muscles of my limbs, my shoulders, my belly, the muscles of my face. Allowing myself to sink into the chair or bed I'm on. Sometimes I accompany all this with a peaceful image. For me it is that of water cascading over rocks and falling, falling, into a pool below. Try it sometime.
As a therapist I've always used my feelings in the session. Since all feelings are bodily events, this sometimes leads to saying things like. "I have a lump in my throat as you talk about your father. What is your body telling you?" My patients now ask me if I'm scared. When I tell them that I am, they ask teasingly. "Are you feeling that in your hips?"
On good days I feel lucky that we live in a time when such miraculous surgery is possible. Our parents and grandparents with the same diagnosis would have spent the rest of their lives in a wheelchair. I'm beginning to embrace the idea that before long I will, at the very least, be walking normally and pain free again.
What will my body make of me and me of my body? We're a team, integrated parts of whatever we mean when we say "I".
Who will I be?
The Buddhists tell us that the only constant in the universe is change.
Lois Meredith, Ph.D.
24 February 2004
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Part II: From Eight Weeks Out
Part III: One year later