Guidelines For Emotional Support Animals - Hope College: Fill & Download for Free

This is an important issue, reminding me of the Terry Schiavo case of some years ago in Florida, on which I also opined with my colleague Roger Blackburn (Gainesville Sun).To answer this question, we need to understand the definition of brain death, and then we need to understand the progression of physiology - the natural history of death, as it were - in the human body. Finally, with these two pieces of information, we can ask the question as to whether a 14 week old fetus CAN be kept alive in a dead host until it is viable.Further, from what was reported in the press, Ms. Muñoz was unresponsive - pulse-less - for an hour prior to return of spontaneous circulation. This means that the fetus was without blood flow for that period as well. One is forced to ponder the state of the fetus' central nervous system after a prolonged period of hypoxia / hypo-perfusion. It will not be a good outcome for the fetus / child even if the mother is forced to play host until term.The other question: Does / should the state have the right to force a family to keep a dead person on "life support" to serve as a host for the fetus ?I use herein some material I have written in the recent past, with references.Brain DeathDefinition of Clinical Brain DeathIn a landmark manuscript, Harvey Cushing described the “Experimental and Clinical Observations Concerning States of Increased Intracranial Tension” (1). Utilizing an animal model and differentiating local compression from a general compression of the brain, Cushing examined the physiology of intracranial hypertension and its effect upon systemic hemodynamics, now known as Cushing's triad (irregular respirations, decreased heart rate and increased blood pressure).In contrast to animal models used by Cushing and others, where the experimentation is undertaken in a controlled setting, the physiology of human brain death remains challenging for multiple reasons: the time of actual brain death may be significantly different from the certification time with significant physiologic changes occurring in the interval, treatment of the patient in the period antecedent to brain death and in the immediate post brain death period may result in abnormalities independent of brain death and, lastly, there will never be a human model of brain death (2). As a consequence, an understanding of brain death physiology is derived from animal models and data inferred from human case series.Somatic death after clinical brain death will inevitably occur in the absence of aggressive support. In an era when brain death was not accepted, prolonged survivorship, with a mean the duration of 23 days, was noted in a study that aggressively maintained brain dead patients (3). Autopsy studies of patients that were declared brain dead revealed histopathologic evidence of necrosis and liquefaction (4).In 1956, Lofstedt and von Reis described 6 mechanically ventilated patients with absent reflexes, apnea, hypotension, hypothermia, and polyuria associated with absent angiographic cerebral blood flow (5). Death was declared when cardiac arrest occurred, between 2 and 26 days after the clinical examination.However, it was after the description of “Le Coma Depasse” by Mollarat and Goulon, in 1959, that the description and understanding of coma and death changed forever (6). These authors presented 23 cases from their Paris hospital in which they described irreversible or “irretrievable coma”. This was coma that was associated with a lack of cognitive and vegetative functions, and went beyond any description of coma that had been previously discussed. This description initiated the discussion and formed the basis of what is contemporarily recognized as brain death. The authors defined the necessity of considering the circumstances of the injury, the role of the neurologic examination, the results of electroencephalography (EEG), and the consequence of brain death on other organs. They found that the majority of injuries to the brain were confined to trauma, subarachnoid hemorrhage, meningitis, cerebral venous thrombosis, massive stroke, and brain death after craniotomy for posterior fossa tumor. In this series, they detailed problems including deterioration of pulmonary function, polyuria, hyperglycemia, and tachycardia. It is intriguing that this paper, even though published in a relatively well known European journal, took more than 15 years before it became known in the United States and Great Britain.In 1963, Schwab and associates reported utilizing EEG as an adjunct for determining death when cardiac activity was present (7). These authors proposed that the patient was dead when: 1. spontaneous respirations were absent for 30 minutes; 2. tendon reflexes of any type were absent; 3. pupillary reflexes were absent; 4. the occulocardiac reflex was absent; and 5. the EEG was iso-electric for 30 minutes.In 1968, Harvard Anesthesiologist Henry Beecher chaired a committee at Harvard Medical School which attempted to define irreversible coma as new criteria for death. The committee defined death as the irreversible loss of all brain function and proposed the criteria necessary to make that determination (8). These included non-receptivity and unresponsiveness, no movements or breathing, no reflexes, and a flat EEG. The committee suggested that the tests should be repeated at 24 hours and, in the absence of hypothermia and central nervous system depressants and with no change in examination, the patient would fulfill criteria for the diagnosis of brain death.Subsequently, concern regarding the relevance of EEG unfolded, with the Conference of the Royal Colleges and Faculties of the United Kingdom publishing the Diagnosis of Brain Death, first in 1976 and then again in 1995. This publication altered the definition from brain death to brain stem death (9): if the brain stem was dead, the brain was dead, and if the brain was dead, the patient was dead. The conference required that the etiology of the condition that led to coma be established, and a search for reversible factors – such as central nervous system depressant drugs, neuromuscular blocking agents, respiratory depressants, and metabolic or endocrine disturbances – be under-taken. A period of observation was recommended and the technique for apnea testing was described (9, 10).The only prospective attempt to develop guidelines for determination of brain death based on neurologic criteria was the 1977 NIH-sponsored study (11). Enrollment required demonstration of cerebral unresponsiveness and apnea, and at least one isoelectric EEG. The investigators recommended examinations at least 6 hours after the onset of coma and apnea, with the examination demonstrating cerebral unresponsiveness, dilated pupils, absent brain stem reflexes, apnea, and an isoelectric EEG. As defined in this study, the apnea examination only required that the patient not make any effort to breathe over the ventilator.The Quality Standards Subcommittee of the American Academy of Neurology formally redefined brain death in 1993, utilizing an evidence-based approach from the literature. They defined criteria for evaluating brain death as the presence of coma, evidence for the cause of the coma, including the absence of confounding factors, such as hypothermia, drugs, and electrolyte or endocrine disturbances. Fulfilling the preceding criteria, brain-stem and motor reflexes needed to be absent. An apnea test was finally established as a criteria and part of the exam to define brain death. The Sub-committee recommended a repeat evaluation 6 hours after the initial evaluation, but recognized that the time was arbitrary and suggested that confirmatory studies should only be required when specific components of clinical testing could not be reliably evaluated (12).Ishii and colleagues evaluated the use of Magnetic Resonance Imaging and MR Angiography (MRA) in patients diagnosed as brain dead by, at the time, standard methods (13). In the four cases they studied, SPECT – using 99mTc HMPAO – scanning before or immediately after the MRI studies showed no uptake of radioactivity, the “hollow skull” sign. MRI findings were diffuse brain swelling, central and tonsillar herniation, and loss of the flow void in the intracranial portions of both internal carotid arteries. These investigators suggest that MRA provides a noninvasive and reliable method for the diagnosis of brain death.Falini and associates (14) followed the structural and biochemical changes in a single patient after severe hypoxic ischemic brain injury, using serial MR and proton MR spectroscopy. While this case report did not touch on the issue of brain death, the biochemical metric of the severe neuronal insult – a sharp decrease in cortical N-acetylaspartate and subsequent increase in choline – are of interest.In another single-case study, Lövblad and Bassetti utilized diffusion-weighted MRI (DWI) to evaluate for brain death (15). They again reported – in a 79 year old woman with sudden onset of coma and Glasgow Coma Score of 4 – transtentorial herniation with compression of the brain stem, the absence of flow voids on T2 weighted images, and the absence of intracranial vessels on MR angiography. The DWI images with severe diffusion coefficient decrements suggested profound ischemia secondary to absent cerebral blood flow. Although only a single case, the authors point out that the DWI may demonstrate severe ischemic changes that are simply not consistent with survival, thus potentially providing a non-invasive method to diagnose brain death.Young and colleagues (16), in a brief review of ancillary studies useful for the determination of brain death, point out that the diagnosis remains essentially clinical and only studies that evaluate for brain perfusion are of merit; the authors note that CT angiogram and MR angiogram may be of use.Although not done in conjunction with an MRI study, Zuckier and Kolano (17), and Sinha and Conrad (18) note the utility of using the accepted 99mTc – HMPAO radio-nuclear study as a confirmatory test for brain death. An obvious potential downside to this technique is the need to move a potentially unstable patient to the Nuclear Medicine suite.Most US institutional policies are modeled after the Quality Standards Subcommittee of the American Academy of Neurology (19).Thus, several things are evident from this review:1. The definition of brain death is a clinical one.2. In the presence of clinical brain death, the body will shut down, on average, 23 days after brain death has occurred. This means that even if we try to keep the body functioning, it will, ultimately, stop working. If this 14 week old fetus needs to be at least 24 to 30 weeks old to survive in the neonatal ICU, then nearly 3 months, not 23 days are needed. It is unliklely that the body of Ms. Muñoz can be kept functioning for that long.3. This has obvious implications. Even if the State of Texas orders Ms. Muñoz act as a host, this will likely not be possible for a long enough period that the fetus becomes viable outside of the uterus.And finally, even if it were possible to use Ms. Muñoz' body as an incubator, the fact that she was in circulatory arrest for an hour before being found means that the fetus / child was without blood flow, oxygen, and nutrients for a prolonged period and will be, most likely, severely neurologically damaged.Is the great State of Texas going to provide financial support to the child and his / her family in perpetuity ? Or will these so-called Right to Lifers behave the way they often do: Very concerned about life while it is in utero, but unresponsive and dismissive after the child is born.Medically, this is a disaster.Morally and ethically, the State of Texas has no right to do what they are doing.It is abuse - of Ms. Muñoz and her family - plain and simple. Texans should be ashamed that their state government abuses the dead and manipulates the emotions of the living.I hope they find forgiveness.References:1. Cushing H. Some experimental and clinical observations concerning states of increased intracranial tension. The American Journal of the Medical Sciences. 1901;124:375.2. Power BM, Van Heerden PV. The physiological changes associated with brain death--current concepts and implications for treatment of the brain dead organ donor. Anaesth Intensive Care. 1995;23:26 – 36.3. Yoshioka T, Sugimoto H, Uenishi M, et al. Prolonged hemodynamic maintenance by the combined administration of vasopressin and epinephrine in brain death: a clinical study. Neurosurgery. 1986;18:565 – 567.4. Black PM. Brain death (first of two parts). N Engl J Med. 1978;299:338-344.5. Lofstedt S. Intracranial lesions with abolished passage of x-ray contrast throughout the internal carotid arteries. Pacing and Clin Electrophysiology. 1956;8:99.6. Mollaret P, Goulon M. [The depassed coma (preliminary memoir)]. Rev Neurol (Paris). 1959;101:3 – 15.7. Schwab R. EEG as an aid in determining death in the presence of cardiac acuity. Electroencephalography Clin Neurophys. 1963;15:147.8. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA. 1968;205:337 – 340.9. Diagnosis of brain death. Statement issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 11 October 1976. Br Med J. 1976;2:1187 – 1188.10. Criteria for the diagnosis of brain stem death. Review by a working group convened by the Royal College of Physicians and endorsed by the Conference of Medical Royal Colleges and their Faculties in the United Kingdom. J R Coll Physicians Lond. 1995;29:381 – 382.11. An appraisal of the criteria of cerebral death. A summary statement. A collaborative study. JAMA. 1977;237:982 – 986.12. Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 1995;45:1012 – 1014.13. Ishii K, Onuma T, Kinoshita T, Shiina G, Kameyama M, Shimosegawa Y: Brain Death – MR and MR Angiography. Am J Neuroradiol, 1996;17: 731 – 735.14. Falini A, Barkovich AJ, Calabrese G, Origgi D, Triulzi F, Scotto G: Progressive brain failure after diffuse hypoxic ischemic brain injury – A serial MR and proton MR spectroscopic study. Am J Neuroradiol, 1998;19:648 – 652.15. Lövblad K-O, Bassetti C: Diffusion-weighted magnetic resonance imaging in brain death. Stroke, 2000;31:539 – 542.16. Young GB, Shemie SD, Doig CJ, Teitelbaum J: Brief Review – The role of ancillary tests in the neurological determination of death. Can J Anesth, 2006;53:620 – 627.17. Zuckier LS, Kolano J: Radionuclide studies in the determination of brain death – Criteria, concepts, and controversies. Semin Nuc Med 2008;38:262 – 273.18. Sinha P, Conrad GR: Scintigraphic confirmation of brain death. Semin Nuc Med, 20123;42:27 – 32.19. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM, American Academy of N. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74:1911 – 1918.

Whether obesity is framed as a disease or not is not the primary factor in stigmatization of obesity. Diseases can be and are stigmatized.What would stop the stigmatization of obesity is a better informed populace.The myth that [math]calories in [/math][math]-[/math][math] calories out = weight[/math] harms efforts to reduce obesity and creates stigma by creating a false belief system about obesity that leads to character assignations of those who are overweight.You’ve probably heard them all.Just the word fat explodes with pejorative assumptions.LazyDumbLow classIgnorantSlobHave I missed any? I’m sure I have.These are all based on the false belief that someone who gets fat does so because:They’re too lazy to exerciseThey’re too dumb to read labelsThey don’t know enough about nutrition to maintain a healthy weightWhat do you expect from the lower classes?They’re couch potatoes who rarely moveWhat is the truth?There are a great many evidence-based hints and even considerable proof that obesity is much more complex than the simplified [math]calories in [/math][math]-[/math][math] calories out = weight[/math] taught in health classes. It’s no wonder that some people give up when what they were taught in school isn’t effective.What do we know about weight that isn’t tied to [math]calories in [/math][math]-[/math][math] calories out = weight[/math]?Hormones affect how our body processes food.Stress and ObesityChronic stress sends signals (cortisol) that increase appetite and reduce our ability to exert self-control that effects weight gain and the difficulty of losing weight.The same person, while not stressed, will be more able to resist foods that cause weight gain and engage in activities and food choices that support weight loss than they are when they are stressed. Stress adversely effects self-control and increases inner urges to eat.Springer’s scientific journal, Current Obesity Reports, published an article, Stress and Obesity: Are There More Susceptible Individuals?, in 2008 where they reported on this connection:“Increased long-term cortisol levels, as measured in scalp hair, are strongly related to abdominal obesity and to specific mental disorders . . . Stress may play a major role in the development and maintenance of obesity in individuals who have an increased glucocorticoid exposure or sensitivity. These insights may lead to more effective and individualized obesity treatment strategies.”[1]Childhood Stress and ObesityThe Journal of Adolescent Health, published Depression, cortisol reactivity, and obesity in childhood and adolescence in 2009, where it was reported that:“The current findings attest to the significance of psychologic states as potential components in models of childhood obesity, and provide conceptual and empirical support for the inclusion of cortisol reactivity in these models.”Longitudinal Stress Experiences and ObesityAn Elsevier journal, Psychoneuroendocrinology, published Stress-related and basic determinants of hair cortisol in humans: A meta-analysis in 2017 where it was reported that:“Our findings reveal positive associations of HCC with stress-related anthropometric (body mass index, waist-to-hip ratio) and hemodynamic measures (systolic blood pressure).”In other words, higher levels of cortisol (the stress hormone) in the historical record hair provides shows that obesity and stress are related.Sleep Deprivation and ObesityThe scientific journal, Current Opinions in Clinical Nutrition and Metabolic Care published, Sleep and Obesity in 2011 reported on the link between sleep deprivation and obesity.[2]“Recent epidemiological and laboratory evidence confirm previous findings of an association between sleep loss and increased risk of obesity.”The CDC[3] declared sleep deprivation an epidemic public health emergency with 35% of Americans experiencing insufficient sleep.Sleep deprivation is a form of stress that causes all the issues associated with other forms of chronic stress and more. Because sleep is when our bodies and minds repair themselves, inadequate sleep means the person is dealing with the effects of chronic stress without the restorative benefits of sleep.Racism and ObesityAn article published in the Elsevier scientific journal, Journal of the National Medical Association, published Coping With Perceived Racism: A Significant Factor in the Development of Obesity in African American Women? in 2011.[4] This is one of many articles that attempts to identify causes of obesity in black women. Research focuses on this demographic because they have the highest percentage of obesity. Racism is stressful. Stress contributes to obesity. Whether their are other reasons for higher percentages of obesity in this demographic is not yet established, but reducing racism and increasing health promoting coping skills would go a long way toward reducing the prevalence of obesity in every demographic.Another Elsevier scientific journal, Social Science & Medicine, published The weight of racism: Vigilance and racial inequalities in weight related measures in 2018, where they discussed how the stress caused by racism effects weight:[5]“Chronic psychosocial stress may play an important role in obesity inequalities. First, research indicates that consumption of high calorie, high saturated fat foods in response to psychological stress results in the release of certain biochemicals known to reduce feelings of stress (Dallman et al., 2003; Dallman et al., 2005). Moreover, psychosocial stress alters metabolism to result in visceral adipose deposition specifically (Dallman et al., 2005). Second, there are racial inequalities in psychosocial stress and social stressors (Jackson et al., 2010; Schulz et al., 2005; Turner, 2009).”Physiology and ObesityThe physiological effects of stress are too complex for this article. If you would like to explore those relationships at the biological level, Regulation of the Hypothalamic‐Pituitary‐Adrenocortical Stress Response provides a starting point.Clinical Practices Fail Obese PatientsWiley’s scientific journal, Obesity reviews, published an article, A comprehensive diagnostic approach to detect underlying causes of obesity in adults, in 2019, where they elaborated a long list of factors that could cause or contribute to obesity:[6]“Obesity is a worldwide growing problem. When confronted with obesity, many health care providers focus on direct treatment of the consequences of adiposity. We plead for adequate diagnostics first, followed by an individualized treatment. We provide experience‐based and evidence‐based practical recommendations (illustrated by clinical examples), to detect potential underlying diseases and contributing factors. Adult patients consulting a doctor for weight gain or obesity should first be clinically assessed for underlying diseases, such as monogenetic or syndromic obesity, hypothyroidism, (cyclic) Cushing syndrome, polycystic ovarian syndrome (PCOS), hypogonadism, growth hormone deficiency, and hypothalamic obesity. The most important alarm symptoms for genetic obesity are early onset obesity, dysmorphic features/congenital malformations with or without intellectual deficit, behavioral problems, hyperphagia, and/or striking family history. Importantly, also common contributing factors to weight gain should be investigated, including medication (mainly psychiatric drugs, (local) corticosteroids, insulin, and specific β‐adrenergic receptor blockers), sleeping habits and quality, crash diets and yoyo‐effect, smoking cessation, and alcoholism. Other associated conditions include mental factors such as chronic stress or binge‐eating disorder and depression.Identifying and optimizing the underlying diseases, contributing factors, and other associated conditions may not only result in more effective and personalized treatment but could also reduce the social stigma for patients with obesity.”[7]Since that is a bit difficult to read in a direct quote, here’s a list of the factors the scientists encourage physicians to investigate before assuming that obesity is related to overeating or lack of physical activity.[8]Monogenetic or syndromic obesityHypothyroidism(cyclic) Cushing syndromePolycystic ovarian syndrome (PCOS)HypogonadismGrowth hormone deficiencyHypothalamic obesityMedicationCorticosteroidsInsulinSpecific β‐adrenergic receptor blockersSleeping habits and quality (keep in mind that the CDC has declared sleep deprivation an epidemic)Crash dietsYoyo‐effectSmoking cessationAlcoholismChronic stressBinge‐eating disorderDepressionGenetic obesity is related to:Early onset obesityDysmorphic features/congenital malformations with or without intellectual deficitBehavioral problemsHyperphagiaStriking family historyAs long as this list is, one of the newer scientific discoveries about obesity is missing as well as one that has been known for a while. Most of these contributing factors have been known for a long while. The news that obesity is not caused solely, or even primarily, by the dumbed down formula that so many lean on to justify their poor treatment of obese individuals, [math]calories in [/math][math]-[/math][math] calories out = weight[/math] is not new news. The knowledge base is continuing to expand but the basics have been known for decades.This childhood cause of obesity was not included in the above list:[9]Prader-Willi Syndrome (PWS)A Dutch scientific journal, NTvG, published an article, Obesitas in de spreekkamer which translates to Obesity in the doctor’s office: First Diagnostics and then Effective Treatment, in 2017 that reported:“In clinical practice, relatively little attention is directed towards identifying underlying causes and contributing factors to weight gain in patients with obesity. However, recognising these "hidden fattening factors" is important as it can lead to more effective treatment strategies. In particular if underlying causes can be solved first, this could help to realise sustainable weight reduction. Besides the well-known lifestyle-related aspects, obesity may be caused or maintained by medication use, endocrine or hypothalamic disorders, monogenetic or syndromic diseases, and mental factors, which may require specific (medical) treatment.”[10]Estrogen and ObesityAn Oxford Academic journal article, Human Reproduction Update, published Ovarian hormones and obesity in 2007 where they began their conclusion with this statement:[11]“We find that estrogens play a leading role in the causes and consequences of female obesity.”Childhood Abuse and ObesityOther studies, such as Associations of child sexual and physical abuse with obesity and depression in middle-aged women, have associated childhood maltreatment as a risk factor for obesity, depression, and eating disorders. For victims of abuse, weight loss may make them feel more vulnerable.[12] The excess weight affords protection against undesired attention, especially sexual advances. Many of these patients regain the weight because they are more comfortable. Until the underlying trauma is healed, they are likely to continue regaining weight following successful weight loss. Treating the trauma should be a priority.In a study of 57,000 women, childhood abuse more than doubled the risk of food addiction.[13] Current estimates are that up to 1 out of 5 children in the United States have a mental health disorder.[14]Let’s pause for a moment. How many people would knowingly choose to kick someone who is down because of horrific experiences they endured as children? Not many people would do so willingly if they were introduced to the scenario in a way that makes it clear that the person was a victim.If we began conversations about weight by talking about the precursors, whether that is the mother’s depression while they were a fetus,[15] childhood abuse, or chronic stress experienced as an adult, few people would treat the word fat as a four-letter word. Few people would kick the proverbial dog while it’s down by stigmatizing obesity, discriminating against individuals who are obese, or subtracting IQ points due to obesity.[16]If a smart person wants to trick someone into believing the smart person is less intelligent than they are, all they have to do is gain weight. — Jeanine JoyGut Microbiota and ObesityThis area of research is very active but human studies have not reached any definitive conclusions, yet.[17] However, animal studies have provided reasons to hope that studying gut microbiota may lead to new treatments for obesity. At least one animal study reported weight loss when a fecal transplant between a lean mouse and an obese mouse was performed.This is an area to watch. It is also something to consider before stigmatizing obesity. We don’t yet know all the factors yet people who are fat are blamed for their obesity. It reminds me of the witch trials that blamed witches for things that the people of the time couldn’t explain because they didn’t know what they didn’t know.Stigma Contributes to the Obesity EpidemicSome people believe that stigmatizing obesity is an effective method of encouraging weight loss. They couldn’t be more wrong.The American Journal of Public Health published an article, Obesity Stigma: Important Considerations for Public Health in 2010, that discussed evidence that stigma worsens the obesity problem.[18]“Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored. Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. We examine evidence to address these assumptions and discuss their public health implications. On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts. These findings highlight weight stigma as both a social justice issue and a priority for public health.”In other words, those who stigmatize obesity contribute to the problem. They are piling on another form of abuse to people who are often victims of abuse, ill, or chronically stressed. Stigma increases the stress obese individuals experience which makes it more difficult to manage their weight!SummarySociety has been attempting to fight obesity for decades; the epidemic of obesity has increased, not decreased, for the duration of the battle. This is an indicator that the war is being waged on the wrong battlefront.Psychosocial stress, whether it is the result of childhood abuse, discrimination, racism, poverty, sleep deprivation, or stigma about obesity, mental health, or a combination of these factors is a significant contributing factor to obesity.We’ve also been fighting against racism, poverty, and childhood abuse for decades with little success except on the racism front.It seems that the advances have primarily benefited minorities who manage to escape poverty. Those who remain in poverty experience far more racism than those who are in middle or upper socioeconomic classes. Or, perhaps I am confusing economic stigma with racism. I haven’t seen research that has been able to separate these two factors. Regardless, the stress caused by racism still effects a large number of Americans.Additionally, with up to 1 out of 5 children experiencing mental health issues, we certainly have not resolved childhood abuse and trauma issues. There is a disproportionate effect on children living in poverty because their environments tend to include more trauma, whether it is violence in the streets or in the home, children living in poverty are exposed to more adverse childhood experiences than those living in higher socioeconomic circumstances. That is not to say that children in better socioeconomic situations are immune from trauma and abuse as they aren’t, which is why all children should be screened for mental health needs.A New (Better) Approach to the Obesity EpidemicThere is one approach to obesity that has not yet had a great deal of support from clinicians or public health officials despite a significant and growing body of evidence demonstrating its efficacy.Psychosocial stress is handled in different ways by different people.[19] One person experiencing a specific situation may not feel stressed while a similarly situated person may feel overwhelming stress from the same situation. After decades evaluating the reasons one person feels low stress and another feels high stress in similar situations, it is clear that our habits of thought and underlying beliefs about ourselves and the world determine how much stress we feel in any given situation.When similarly situated person is used, it means that someone with the same economic and social resources, age, race, and education are being compared — not someone with money vs someone without money or someone who is married with someone who is single. It is not the situation, but the way the situation is perceived that determines how much stress is experienced by a specific individual.Coping methods for dealing with stress vary from dysfunctional and maladaptive methods that make the situation worse. These methods include drug and alcohol abuse, self-criticism, avoidance, eating, and a host of other common strategies. The difference between dysfunctional and maladaptive methods is how long it takes for the method to make things worse.Then there are palliative methods which are the most commonly recommended methods of stress management. When someone goes into palliative care, they are given comfort care but no attempts to cure them are made. When it comes to psychological stress reduction, palliative has the same definition. It soothes but does not cure the cause of the stressors.Adaptive coping goes a step further, building skills that make the person better prepared for the stressors encountered. While this method is better than dysfunctional, maladaptive, and palliative care, unless the skills learned increase the skill the person develops to deal with all types of stress they are generally effective on a situational basis. For example, learning how to make a household budget can alleviate financial stress from poor money management but does nothing for the stress of job insecurity or discrimination experienced at work or when job hunting.Advanced coping skills are a level up because they train the mind to use psychological flexibility to change the level of stress experienced without first requiring the situation to change. This opens up resources the individual can then use to change their situation.The final level, Transformational Coping Skills, is the result of continuously applying Advanced Coping Skills. Transformational Coping Skills are in place when the mind automatically perceives situations in ways that are less stressful. Individuals who reach this level are resilient and naturally adjust to life’s challenges without suffering adverse consequences experienced by those whose stress management skills are less developed.Benefits of Increased Healthy Coping SkillsWe cannot stop stressors with the wave of a magic wand but we can change the impact those stressors have on health and the quality of life individuals experience by teaching healthy, evidence-based coping skills.Exploring the research related to this topic reveals that many of the social problems that contribute to disparate health outcomes are driven by dysfunctional and maladaptive coping skills.Whether it is childhood outcomes, workplace engagement or burnout concerns, or mental health, developing healthy habits of thought improves outcomes.An interesting thing happens when someone is no longer detrimentally effected by a stressor, such as stigma. It stops effecting their outcome, yes, but beyond that, those who take pleasure in kicking someone when they are down don’t get the pleasure because their verbal and behavioral blows no longer have the desired effect.On the flip side, someone who feels good (which is an outcome of healthy habits of thought and coping skills) has no desire to put someone else down. When you feel authentically good, making someone else feel bad would make you feel worse. To preserve their own good feelings, people who feel good don’t deliberately make others feel bad.There are strong arguments in favor of schools and employers teaching these skills. The solutions make financial sense and there are strong public health reasons for pursuing this path. That would move us toward a solution instead of simply renaming the problem.Expanded Information Related to this TopicJeanine Joy's answer to Do you find this as an agreeable possibility that sometimes it's the bad brought up in childhood that manifests as a psychiatric illness later in life? Why or why not?Jeanine Joy's answer to Should you teach kids to thrive in your classroom, as a skill to be taught?Regulating Emotions to Beat Opioid AddictionA broader view of solutions for the physician burnout public health crisis: prevention and recovery. When my husband told me that 10 prominent health system CEO's committed to do 11 things about the healthcare crisis that is physician burnout, I was excited.How Should Your Organization Prioritize Employee Stress and Mental Health?AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE... - PubMed - NCBII’m aware that some folks would prefer to hear from an MD. Here’s an MD also saying that obesity isn’t calories in - calories out = weight.Amy Chai's answer to Why did the American medical association decide to label obesity as a chronic disease given that it’s obviously a condition?Amy Chai's answer to Are we normalizing obesity? Is this foresight to an unhealthy future for greater society?Footnotes[1] Stress and Obesity: Are There More Susceptible Individuals?[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632337/pdf/nihms-459205.pdf (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632337/pdf/nihms-459205.pdf)[3] CDC Works 24/7[4] Coping With Perceived Racism: A Significant Factor in the Development of Obesity in African American Women?[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617791/pdf/nihms879406.pdf (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617791/pdf/nihms879406.pdf) [6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850662/ (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850662/)[7] A comprehensive diagnostic approach to detect underlying causes of obesity in adults[8] A comprehensive diagnostic approach to detect underlying causes of obesity in adults[9] Prader-Willi Syndrome (PWS)[10] [Obesity in the clinic room: diagnostics first, followed by effective treatment].[11] Ovarian hormones and obesity[12] How childhood trauma can affect mental and physical health into adulthood[13] Abuse victimization in childhood or adolescence and risk of food addiction in adult women[14] What Are Childhood Mental Disorders? | CDC[15] Foetal exposure to maternal depression predicts cortisol responses in infants: findings from rural South India.[16] Obesity Discrimination in the Recruitment Process: “You’re Not Hired!”[17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5933040/pdf/IJE2018-4095789.pdf[18] Obesity Stigma: Important Considerations for Public Health[19] Jeanine Joy's answer to How do people respond to psychological stress?

How do you actually take your feelings and emotions out of a situation to be able to listen to God and to be able to do what's right?This is a very good question. Hearing accurately from God goes beyond suspending our feelings and emotions (which are one and the same). Besides that, God often uses our emotions to communicate with us. So, eliminating them from our process is more likely to cause us to miss the mark rather than hit it. As a matter of fact, the whole idea of “emotions” is a rather new concept (it wasn’t until the early 17th century that the word “emotion” appeared in English — prior to that they were mostly referred to as passions or affections). Today we can list and describe them — joy, anger, sadness, fear, contempt, etc., but we really don’t do a good job of defining them. Modern psychology has let us down in this area and I think it’s much better to simply accept emotions as an indicator of the perceived fulfillment (or lack of fulfillment) of our desires and longings rather than excising them in order to hear from God.Dr. Ed Payne, retired professor from the Medical College of Georgia, a brilliant thinking Christian, offers this definition:Emotion: "Negatively, the momentary (acute) and ongoing (chronic, continuous) disturbance within the mind (soul, spirit) caused by the discrepancy between perceived reality and one's desires." (From A Definition of Emotions.) Positively, emotions result from the expectation or actual fulfillment of one's desires…”So, if emotions are not to blame for our difficulty in hearing from God, what is? This is the more important part of the question. Attitudes and behavior. We are pre-programmed and conditioned with sinful, worldly attitudes that inhibit us from hearing accurately from God."For my thoughts are not your thoughts, neither are your ways my ways," declares the LORD. — Isaiah 55:8 NIVOur thoughts and desires, our attitudes and actions, are corrupted, crooked, and perverted by the fall of mankind and sin.They have dealt corruptly with him; they are no longer his children because they are blemished; they are a crooked and twisted generation. — Deuteronomy 32:5 ESVThe problem, it seems, is straightening out our crooked ways and this is the profound work of God in us:In all your ways acknowledge him, and he will make straight your paths. — Proverbs 3:6 ESVNow, the challenge is how do we acknowledge Him in all our ways, in systematic ways, that essentially rewire our neural networks (or our hearts and minds), and change us from the inside out, making straight our internal crooked paths? I submit that the answer to this question is not attained by casual or academic study, but in God’s crucible of suffering where we are utterly desperate and the answer is crucial. Once upon a time, I found myself in such a place and I will share what God revealed to me in the hopes that a reader may find it helpful in their own circumstances. For several months, the following became a morning devotion and a repeated daily meditation and prayer. Applying it produced a profound change in me that remains. There are seven steps and I consider them like footsteps of Christ leading me out of the wilderness of my struggles. Here they are:Don’t Panic — Stay Calm and SteadyDon’t Blame — Cover ShameDon’t Try to Escape — Stay on the PathDon’t Isolate Yourself — Find Your FriendsDon’t Worry — Cast all your Cares on HimDon’t Stay Where you Are — Follow the JoyDon’t Glorify Mankind — Glorify GodFor further elaboration, read on.#1 Don’t Panic — Stay Calm & Steady“…Let not your heart be troubled, neither let it be afraid.” — John 14:27 ESVThere's no need to panic. Slow down, breathe deeply, relax -- whatever is happening or seems to be happening, don't worry; stay calm and steady. If you react to circumstances in fear, you’ll not hear from God and the situation will likely get worse.The fast heartbeat, quick breathing, and even quicker temper aren’t the only problems; often we go immediately into self-defense mode, desperately trying to explain why the problem is not our fault. That failing, we launch into all the reasons why the problem is our fault. And then we worry about what others will say or think about us and our focus turns to managing our public image rather than solving the problem! This kind of thinking takes up a lot of time and energy and goes nowhere. Even so, it does no good to say to someone, “Stop it!” That approach just ends up sounding critical and no one listens to critical people.But the fact is, someone needs to tell you to stop this behavior, and it has to be someone that you trust and will listen to and follow their instructions… and that someone can be YOU! Yes, you can tell yourself what to do and indeed, you must. If your problem is such that you can’t figure it out yourself, then you need input from outside yourself — but you can’t hear anything from outside yourself with all that racket going on inside your head!So go ahead, tell your soul to knock it off. Get yourself quiet so you can process something other than what’s on the mental merry-go-round in your head.“But I have calmed and quieted my soul, like a weaned child with its mother; like a weaned child is my soul within me.” — Psalm 131:2 ESV#2 Don’t Blame — Cover Your (His, Her, Their) ShameQuieting our souls is a means to an end, not the end goal. Staying Calm and Steady gets us to the starting point.Next we need to deal with shame. If we don’t deal with shame, it has a way of obscuring and twisting everything we perceive. Feeling ashamed is the worst. Shame hurts worse than guilt. It is much worse than guilt. Guilt is: I did something bad. Shame is: I am something bad; I am unlovable. The effect it has on us is that we begin to believe that we deserve to have something bad happen to us — it’s our just desserts! This belief that we deserve trouble coming upon us gets in the way of solving problems. If we believe that it’s our fate to suffer punishment, then why should we resist? What’s more, sometimes we will even create a problem where no problem exists simply because we think we deserve punishment!To deal with this, first, we need to admit that we’re not perfect — we all screw up from time to time. That eventually leads to getting caught, and someone pointing out our misdeed, and then identifying us as the culprit, and finally demanding a confession. Having to admit we did something wrong is uncomfortable as it means we have to acknowledge that we’re guilty of sin, which makes us worry that if we do too many bad things — if the bad stuff we do outweighs the good stuff — then we will not be loved anymore. We spend a lot of time feeling guilty and dodging shame. Many people think if they do more good than bad, that’s all that matters, so they keep a mental scorecard of their deeds. As long as they try to do good most of the time, they cut themselves some slack and excuse a bit of bad behavior now and again. But sometimes they mess up really bad and feel they can never balance the scale again — they are lost to evil, so they think — a rather desperate state of affairs.It’s best to get it over with and admit it: we are in terrible shape. Shame is the lot of mankind. All have sinned and fallen short of the glory of God. But, the good news is that it's covered, the penalty paid for. The blood of Jesus is what covers our shame. To deny our shame or speak positive thoughts over ourselves without acknowledging Jesus, is kind of a deception — but deep down we really don't fool ourselves. So, cover the shame. Rejoice in the blood of the lamb, which washes us clean, no matter what our guilt, no matter how shameful. It is our savior that has done this for us out of love for us.“…these are the ones coming out of the great tribulation. They have washed their robes and made them white in the blood of the Lamb.” — Revelation 7:14 ESVA bit more about shame... it started in the Garden of Eden when Adam and Eve realized they were naked. Their first instinct was to cover their shame — their nakedness — with fig leaves (a poor, fragile covering that didn't last long and was easily torn away). God provided them with animal skins instead. God shed blood to cover shame. That has always been the penalty (and remedy) for sin: death. Then came Moses’ law and the animal sacrifices. And finally, the ultimate sacrifice: God's Holy Son — the only perfect sacrifice that ever could eternally ransom us from shame.The key to covering shame is forgiveness through the shed blood of Jesus Christ — receiving God’s forgiveness of our sins by it. Though offered, critical to receiving God’s forgiveness is forgiving ourselves. We cannot hold ourselves accountable for something that God has released us from — in that case, we are putting our own rules above God’s law. We are rejecting the price Jesus paid, his sacrifice, his ransom for our sins, as not good enough — as if he needed to suffer more for our particular transgressions! I think of it as a sin not to forgive ourselves in light of what Jesus did.Covering our shame is what Jesus did — our shame is what causes our brokenness — and what desperately needs healing.Shame is basically us telling ourselves (or others) that we (or they) are not good enough, that we (or they) are unworthy, of no value, and deserving of punishment.First, recognizing and admitting our condition is a vital; it is, in essence, confession. Second, we are required to repent, to turn away from our sin. And third, finally, we must actively receive the healing and restoration that God offers us:“The Spirit of the Lord GOD is upon me; because the LORD hath anointed me to preach good tidings unto the meek; he hath sent me to bind up the brokenhearted, to proclaim liberty to the captives, and the opening of the prison to them that are bound; To proclaim the acceptable year of the LORD, and the day of vengeance of our God; to comfort all that mourn; To appoint unto them that mourn in Zion, to give unto them beauty for ashes, the oil of joy for mourning, the garment of praise for the spirit of heaviness; that they might be called trees of righteousness, the planting of the LORD, that he might be glorified.”The mystery of healing our brokenness is hidden in this brief passage:“...to give unto them beauty for ashes, the oil of joy for mourning, the garment of praise for the spirit of heaviness;”Beauty for ashes: Ashes are our failures, the burned up wreckage of our unrealized hopes and dreams, our broken relationships and our personal failures. We cling to them tenaciously, refusing to let them go, even when there is no hope of their resurrection. Continuing to nurse them only causes us pain and stagnation. Jesus offers to exchange our ashes for beauty. It is a trade — we must let go our ashes in order to receive the beauty he promises. The beauty does not come instantaneously. Jesus takes our ashes and invests them; the ashes become fertilizer for the soil of our hearts, in which he plants the seed of His Word. The more more ashes, the more bounteous the crop — 30, 60, 100 fold. He takes something painful and ruined and grows something beautiful from it. Like he takes discord and blends it with melodies to create beautiful harmonies. Like He takes the bitter and mixes it with the sweet to create bitter-sweet flavors. Like He takes fantasy and mixes it with understanding to create imagination.Oil of Joy for mourning: Mourning saps our strength, robbing us of life’s virtue, its energy. As we hand over our ashes, we must also cease our grieving. It’s as if the oil, our life’s energy or fuel, is being used up to in the dream-burning that produces our ashes. As we give up our mourning, our life-energy is released to burn with the bright light of joy. Oil is for burning, and we will either turn the flame of our attention (our focus) toward the failures of our past or toward the hopes of our future: the former produces mourning, despair, ashes — the latter, joy, hope, peace.Garment of praise for the spirit of heaviness: Garments are coverings for our bodies for hiding the shame of our nakedness. Adam and Eve sewed the first garments from fig leaves, and God replaced these inadequate coverings with animals skins, shedding blood as a sacrifice to cover their sin. After the resurrection of Christ, all robes of righteousness are dipped in blood, the blood of Jesus.He is clothed in a robe dipped in blood, and the name by which he is called is The Word of God.— Revelation 19:3These are the wedding garments, which are sufficient in every way to get us to the wedding feast, where our shame will not be only covered, but completely removed. He takes the damaged, frayed threads of our lives, mixes them with his precious blood and weaves them into beautiful, intricate garments, covering our shame making us pure in the sight of the Father. These are our wedding garments, the ones we are required to wear to the marriage supper of the Lamb. Like the other elements for healing brokenness, there is also an exchange involved. Instead of remaining bowed with the heaviness of shame and despair, thinking ourselves unworthy, we must lift up our hands in praise to the one who redeemed us. This is not merely and outward act of obeisance — it changes us on the inside. It encourages us, it emboldens us, and it strengthens our resolve in the face of danger and despair.Praise is encouraging someone by listing their positive attributes — it is lifting them up. We praise when we encourage a child trying to learn a new skill, or when we cheer a sports team to inspire them to reach for victory on the field. When we praise God, we are recognizing that our deliverer is indeed the one who can raise us up, lift us out of our dilemmas, and set our feet on solid ground. He is the captain of our salvation, and worthy of praise. When we praise God we are also lifting ourselves up, building our confidence (for He is able), encouraging and emboldening ourselves to do great things. Let praise be continually upon our lips.All this that we might be called trees of righteousness, the planting of the LORD, that he might be glorified. This is how God plants and tends his Garden.Now, this picture of a “planting of the Lord,” a garden, is worthy of developing a bit more.Consider the tree:And he shall be like a tree planted by the rivers of water, that bringeth forth his fruit in his season; his leaf also shall not wither; and whatsoever he doeth shall prosper. — Psalm 1:3 KJVFor he shall be as a tree planted by the waters, and that spreadeth out her roots by the river, and shall not see when heat cometh, but her leaf shall be green; and shall not be careful in the year of drought, neither shall cease from yielding fruit. — Jeremiah 17:8 KJVOf course, to be like the tree in the above passages you must be planted by the river. If you are not, and you express your desire to be close to God, thus giving Him permission, you are in for a transplanting:But he answered and said, Every plant, which my heavenly Father hath not planted, shall be rooted up. Mt. 15:13And the river it speaks of is the River of Life that flows from the throne of God.And he shewed me a pure river of water of life, clear as crystal, proceeding out of the throne of God and of the Lamb. Rev 22:1Once we realize that we are likened unto trees, it’s clear that the soil is where we’re planted, and God wants to move us into the garden and plant us by the River of Life, a lot of things become clearer but I get a bit nervous when I consider Ecclesiastes 11:3,whether a tree falls toward the south or toward the north, wherever the tree falls, there it lies.Whenever my tree falls, I definitely want it to be in the garden!Other interesting things to think about are that broken people are not in the garden and when a broken person gets patched up, tended, and fertilized with the ashes of our past failures — it still needs water, the cleansing rain that falls from heaven, showering us with God’s forgiveness (the source of the rain is always the River of Life). And indeed, it does rain on the just and the unjust.For he makes his sun rise on the evil and on the good, and sends rain on the just and on the unjust. Mt. 5:45But, the rain does us no good if we’re holding up an umbrella — we don’t receive God’s forgiveness if we don’t forgive ourselves.The other requirement is time. Seeds don’t sprout up into trees instantaneously. You must allow time for the rain and the fertilizer do their work in the soil so the seed can germinate and grow. This requires a farmer’s patience (and lot’s of mercy). Sometimes, God can fertilize and water a tree right where it’s at and transplant it when it’s stronger. Sometimes, the soil is so toxic, the plant needs to be plucked up and temporarily planted in a nursery until it is strong enough to replant.All this to say, don’t blame either yourself or others. Repent and receive God’s forgiveness and forgive others as well.#3 Don’t Try to Escape — Stay on the PathDon't try to escape. When we find ourselves in spiritual distress, the desire to escape, to run away, whether by physically running away or just fantasizing, the effect is the same: suspension of God's restoring process. Recognize the gentle hand of God orchestrating your circumstances to bring you to the place he wants to for your good — and don't try to escape. If you are in a trial, attempts to escape just prolong it. Just as God brings us to that place of discomfort where we must deal with the issue he is targeting, our inclination is to look for an escape route, something to soothe and anesthetize our pain, to distract us from our discomfort.This is where Satan easily tempts us. We tend to blame God for our suffering (why does he not deliver us from our painful dilemma?) and we willingly take the bait that Satan offers to “soothe our pain” as if he was offering us a “bridge over troubled water,” be it drugs, alcohol, excessive food, pornography or some other escape, all lying promises offering us false comfort. Sometimes what is for our good may appear to us (erroneously) to be for our harm — and something that appears to us to be for our good, may be intended for our harm.Many people get stuck here, wandering around, lost in their own wilderness, round and round the mountain, because every time God brings them to the crux of the matter that God desires to change in them, they run away. Don’t try to escape God’s training. The next time you come to that fork in the road, stay on the straight path and see what it is that God has for you — God has placed the relief we seek just ahead on the path, but we tend to take our detours just before we could see God’s provision and find ourselves in the same miserable place again and again with no hope in sight — it’s because we keep taking the detour too soon in our effort to escape our difficulties.#4 Don’t Isolate Yourself — Find Your Friends“Two people are better than one, because they can reap more benefit from their labor. For if they fall, one will help his companion up, but pity the person who falls down and has no one to help him up. Furthermore, if two lie down together, they can keep each other warm, but how can one person keep warm by himself? Although an assailant may overpower one person, two can withstand him. Moreover, a three-stranded cord is not quickly broken.” — Ecclesiastes 9-12 NETDo you actually have any friends — real friends, people you can count on to support you when things go wrong and you’re life is a mess? Friends do not include family members, employers or employees, or mentors (people you depend on or who depend on you); friends do not include social media “friends” that you’ve never met, nor acquaintances, fans, or admirers who only know the public image that you project; and friends don’t necessarily include fellow members of groups, associations, social gatherings, or churches (though a few of these may certainly become friends).All of the people listed above may have a place in your life but they are not substitutes for real, face-to-face friends. So, what are real friends? People that you know intimately — and who know you as well. They have no illusions about your greatness or lack thereof. They know your strengths and your weaknesses and they come to your aid when they know you are vulnerable as you do for them. They are not merely there to cheer on your carefully crafted public image — they really care about you.The key to establishing real friendships is the cultivation of trust — loyalty. If you do not have friends that you trust, you do not have friends.Trust is THE thing among friends.No matter what your social media profile says, you do not have 1,000 friends, or 100, or even 25. You simply don’t have time to connect deeply with that many people.If you don’t have any real friends, then get some — they are essential to thriving in life and you’ll never find the true Land of Milk and Honey without them. Start with one, then add another and another. Try to always have at least two or three friends in your life that you can count on, who will be there for you.Sometimes you lose a friend, either through separation, personal failure, sickness, death, or betrayal. The loss of friendship is always painful and often our response is to withdraw to avoid further emotional pain. Paul Simon immortalized this kind of response in his song, “I am a Rock.” Here is a brief excerpt quoted for the purpose of commentary:I AM A ROCKI am a rock,I am an island.I've built walls,A fortress deep and mighty,That none may penetrate.I have no need of friendship, friendship causes pain.It's laughter and it's loving I disdain…I won't disturb the slumber of feelings that have died.If I never loved I never would have cried…I am shielded in my armor,Hiding in my room, safe within my womb.I touch no one and no one touches me…Isolation is not a good strategy for escaping the pain of loss, rejection, abandonment, betrayal — or for dealing with a crisis. It is the suspension of trust. It basically says, “I can trust no one but myself. I must look out for #1 because no one else will!”Think back to a time with a trusted friend and remember how conversation was so fluent and easy, it seemed you could finish each other’s sentences. Now remember a time when trust was broken. The easy flow of communication ended abruptly; free flowing banter was replaced with short legal phrases, and intent was nearly impossible to discern. To someone viewing your conversation, it resembled watching two TV sets facing each other, showing different movies with the sound turned off!When you have isolated yourself, it is like being alone behind your own castle walls, the doors and gates shut tight and the windows darkened. You long for information from outside. And you sometimes get it — like messages written on scraps of paper wrapped around stones tossed over your walls. As you unwrap and read the messages, you find they contradict each other. There is no way to know what is true and what is maliciously feeding your doubts and fears. This kind of isolation produces a loneliness that is hard to endure — though in the middle of a crowd, you are alone.“One who has isolated himself seeks his own desires; he rejects all sound judgment.” — Proverbs 18:1 NETThe answer is that you must learn to open your windows and doors again so that you can see what’s really going on. You must learn to trust again.Here’s how to do that. Recognize that trust is not an on/off switch, where you either trust someone or you don’t. Instead, view trust as a boundary that you control by giving or withholding permission. You decide who to trust, what to trust them with, when to trust them, where to trust them, why you trust them and exactly how you trust them. It’s like deciding who to grant permission to access your home, your private thoughts, and ultimately your life. You might meet someone on the street and invite them to your gate, into your yard, up on your porch, in your entryway, gradually, over time, building trust and granting more intimate access to your life. If the person betrays your trust, you do not give them further access and in some cases, if the breach cannot be repaired, you should evict them entirely from your life and start over, looking for a more reliable friend. Be deliberate and careful about this: sometimes a restored friendship is stronger than a friendship that has never been tested. Soon, you’ll develop the skill to recognize trustworthy people more quickly; making new friends in new places and under new circumstances will become much easier.When I was in my teens, I read the classic book by John Steinbeck, The Grapes of Wrath for an English class. At the time, I felt awkward about the ending where a teenage girl, Rose of Sharon, who had recently lost her child feeds a starving old man, a stranger, from her milk-laden breast. I remember some of the girls in my class being grossed out by the thought of it, wrinkling their noses and exclaiming, “Ewwww!"As I neared 40, I thought of the passage again. I was going through a crisis in my life and I awoke from a dream of my wife suckling our baby boy, a scene I had enjoyed watching many times when he was an infant: our hungry, frantic child grasping for her breast and latching on to her nipple, sucking eagerly, seeming to become drunk from her milk as she smiled at our darling's face.I wondered at the significance of the tender dream. Then the memory of Rose of Sharon nursing the old man back to life came to my mind. Such compassion, I thought, and the phrase “the milk of human kindness” wafted into my brain. I looked up the quote and found its origin to be from Shakespeare, a quote from Lady MacBeth goading her husband to do evil to expedite the fulfillment of her selfish ambition, “Yet do I fear thy nature, It is too full o’ th’ milk of human kindness to catch the nearest way.” She goes on to say that, if she'd sworn to do it, she would not have hesitated to take her own baby “while it was smiling in my face” and to “have pluck'd my nipple from his boneless gums, and dash'd the brains out.”Now there's a comparison: Rose of Sharon and Lady MacBeth! The poor childless mother overcoming her natural modesty to feed a starving old man from her breast and the rich and powerful woman sacrificing the milk of human kindness toward her own child and the life of the child itself on the altar of selfish ambition!Not all people are capable of giving and receiving comfort and compassion as they ought. It is our mission to become such and to seek out others who have done the same or are in that way graced by God. In short, seek out people like Rose of Sharon and avoid those like Lady MacBeth — especially in a crisis!Another thing to consider is the Biblical sacrament of communion where Christians consume bread and wine in remembrance of Jesus’ sacrifice. Of the wine, Jesus said, “for this is my blood, which confirms the covenant between God and his people. It is poured out as a sacrifice to forgive the sins of many.” Matthew 26:28 NLTThe sacrificed blood of Jesus provides restoration of the vertical relationship of man to God, paving the way for us to fulfill the first and greatest commandment, Love the Lord your God with all your heart, mind, soul and strength.Of the bread, Jesus said, “Take, eat: this is my body, which is broken for you: this do in remembrance of me.” I’m sure the disciples thought back to Jesus’ words earlier when he said, “I tell you the truth, unless you eat the flesh of the Son of Man and drink his blood, you cannot have eternal life within you.” What a relief! Jesus finally confirmed that He had not been talking about some strange rite of cannibalism! But perhaps He had something more in mind than a reminder of His physical suffering on the cross. In 1 Corinthians 12:27, Paul reminds us that Christians — people — are the body of Christ — not just His physical body or the bread of communion: “All of you together are Christ's body, and each of you is a part of it.” He says, “…If one part [of the body] suffers, every part suffers with it; if one part is honored, every part rejoices with it.” So, on a deeper level, the bread of communion reminds us of the second commandment, our horizontal, man-to-man, relationship: “Love your neighbor as yourself.” Here it is again in John 13:34-35, “Love one another. As I have loved you, so also you must love one another. By this all men will know that you are My disciples, if you love one another.”The Bible says of Jesus that he grew in favor with God and with man; let us do the same. There is no time when the milk of human kindness, the ministry of true friends, feels so good as when we’re going through a crisis — sometimes, it may be exactly what’s needed to get us through.Perhaps you realize that you’re short on friends and recognize that you need them. The next thing to do is acquire and retain some friends. The reward is worth the effort. As George MacDonald said, “Few delights can equal the presence of one whom we trust utterly.”Maybe it’s been a long time since you’ve had a close, trusted friend; here are some tips to get you started.First, let’s look at a passage from Proverbs, the book of wisdom:A man that hath friends must shew himself friendly: and there is a friend that sticketh closer than a brother. Proverbs 18:24That’s a lot like the golden rule:“Do to others whatever you would like them to do to you.” — Matthew 7:12 KJVAs this relates to making and keeping friends, simply think about what you want and need from your friends and start doing that to others in your path. Those that are good friend candidates will respond in similar friendly fashion.A few guidelines:Be considerate. Don’t just dump on your friends. Everyone needs to unload their burdens to a sympathetic ear from time to time — but if it gets to be a habit, you can wear out your friends (and they’ll start avoiding you). Sometimes, they may have even greater burdens than you do, so you need to listen to them too. Otherwise, it will start to feel one-sided for them and they will look toward others rather than you.Cultivate a few close friends, like two or three. This has several advantages:You don’t wear out your welcome by too much constant contact with one person. Spreading out your troubles among several friends lightens the load you’re putting on them.You can get more and varied opinions and input.If one friend is for some reason unavailable in a time of need, you can turn to another.Friends are not just for sharing troubles. Do fun stuff too. Eat, drink, recreate, sometimes just be together.If there are no potential friends along your daily path, change your daily path. Go to church, join a group, volunteer at something that inspires you.Be open to new friends even if you already have some.If you need some inspiration for working on your friendships, try listening a few popular songs that describe true friendship. Yes, even popular culture sometimes recognizes the benefit of true friendship:“With a Little Help From My Friends” - Beatles - 1967“You’ve Got a Friend” - James Taylor - 1971“Lean On Me" - Bill Withers” - 1972“Thank You for Being a Friend” - Andrew Gold - 1978“That's What Friends Are For” - Dionne Warwick and Friends - 1986“I'll Be There for You” - The Rembrandts - 1995“Count on Me” - Bruno Mars - 2010There is one more important issue to tackle regarding friendship: division — the things that come between individuals and groups to divide us and prevent camaraderie and real friendship. These insidious barriers to connecting with fellow sojourners in life include all the incendiary hot topics of the day including: age, wealth, class, race, nationality, gender, sex, politics, culture, religion, dress, style, manners, cultural differences, speech… there is no end to what can divide us.Even doctrines of diversity and inclusion are divisive. As the prophet Amos said, "Can two walk together, except they be agreed?” In answer to Amos’ rhetorical question, “They can’t.” These many divisions won’t be healed by discourse, argument or compromise. Such efforts only bring more division and separation, each party retreating to their own camp in righteous indignation, disavowing, shunning and ultimately divorcing those with whom they disagree or at best, “agreeing to disagree.”When people with deep rifts in their outlooks are forced together through compromise, we rightly call the arrangement an “unholy alliance,” describing a cobbled together unity that satisfies no one and rarely lasts long. A threat or common goal may cause divisions to be overlooked temporarily among those bound together for defense or advantage, but only until the threat subsides, or the objective is achieved.This is not to say that we can’t or shouldn’t have differing opinions — we all have them. However, it is good to remember that wherever we differ, one or both of us are wrong — and, invariably, we all think the other person is wrong. The rub comes in our thoughts and actions toward the person whom we perceive to be wrong. It is also good to remember that, when we are most sure of ourselves, we are often at our most vulnerable.Wherefore let him that thinketh he standeth take heed lest he fall. — 1 Corinthians 10:12 KJVI returned, and saw under the sun, that the race is not to the swift, nor the battle to the strong, neither yet bread to the wise, nor yet riches to men of understanding, nor yet favour to men of skill; but time and chance happeneth to them all. — Ecclesiastes 9:11 KJVYet it is not just in matters of chance and the future that our human wisdom fails us. Our own cleverness often betrays us.For the wisdom of this world is foolishness with God. For it is written, He taketh the wise in their own craftiness. 1 Corinthians 3:19 KJVSometimes it is not even God that thwarts our presumptuous hubris — we’re sometimes prone to embrace folly on our own.“Some ideas are so stupid that only intellectuals believe them.” ― George OrwellSo, what is the solution? How can we walk together in friendship, transparency, and authenticity when so much inevitably divides us as we get to know each other better? For the follower of Jesus, the answer is simple. In the words of Jesus himself:“And I, if I be lifted up from the earth, will draw all men unto me.” The closer we get to Jesus, the closer we get to each other.#5 Don’t Worry — Cast All Your Cares on HimBring all your troubles to Jesus in prayer and leave them at the foot of the cross. Everything that causes you to feel unforgiving; everything that makes you feel condemned or want to condemn others; everything that makes you fearful or anxious. Troubles come at us from one of three areas: 1) finances 2) relationships 3) health, or some combination thereof. If we dwell on the problems, they flap round and round in our heads until we become exhausted and we cannot do anything. Surrender them all to Jesus, one by one, until you cannot remember another thing to worry about -- empty yourself of all your concerns. Leave them all at the foot of the cross. Resist picking them up again.Cares, problems, are like birds and are dealt with by prayer. There are two kinds of cares. Using the bird metaphor, there are white ones: doves, and black ones: ravens. Let’s expand the metaphor to explore this further. Consider the doves first. The doves are legitimate concerns; you need healing, you need financial provision, you need to resolve a relationship problem. So you offer up a prayer for each concern (each concern has its own bird). Your prayers are like messages written on scraps of paper and tied to the legs of doves, like carrier pigeons. Your prayers are not properly registered in Heaven until your pigeon arrives — if you’re holding on to the pigeon’s feet, it never gets to Heaven. Once you’ve spoken your prayer, let it go — send it off to Jesus —“Cast all your anxiety on him because he cares for you.” — 1 Peter 5:7Casting your cares on Him is not like casting a fishing lure, where you reel in back in; you must fully let it go, cast it away, all of it — don’t hang on to any of it. The dove will return in God’s time with the answer. It shouldn’t fly in the window and flutter about your head; it should come to the front door and ring the bell in a nice orderly row with the other doves as prioritized by the Father. If you find that it’s come back, without an answer, flying about your head and troubling you, send it off again — it is still a care, a worry. Do not dwell on it, or let it dwell on you.The black birds are cares that are not legitimate concerns. They are self-doubts, feelings of unworthiness born of accusation, guilt, and condemnation. I’m not talking about Holy Spirit conviction here; if you’ve sinned, repent and ask God for forgiveness. Once that is done, you must banish the troublesome dark creatures. As the black birds flutter about your head, reach out and grab one. Pray over it, take it to the window, toss it out directing it to Jesus. It should not come back. If it does, repeat the process. Do not entertain it or consider its message once you have repented and asked for forgiveness.As an illustration of this, I think of the birds Noah sent out (as prayers) from the ark at the end of the great flood; the black raven did not return. The white dove returned with empty beak only to be sent out again, the second time returning with an olive branch — the answer to Noah’s prayer.Continue casting out the birds until there are none left in the attic of your mind and your mind is clear and at rest, free of anxiety and worry.#6 Don’t Stay Where you Are — Follow the JoyGet up, pick a direction, and start moving. Don't wait for direction. Get up and do your best at whatever is before you to do — take up your mat and walk. That's how hope works. It is different from faith — with faith, you have something to go on, an idea, a specific direction to go in. Hope is for when you are alone and in the dark. Hope is the stuff of miracles. Hope is:"An intense anticipation itself transforms possibility into reality; our desires being often but precursors of the things which we are capable of performing… Hope is the companion of power, and the mother of success; for who so hopes strongly, has within him the gift of miracles." — Samuel SmilesWe are like ships in the water and cannot be steered unless we are moving. Sometimes God has to rock our boat just to get us moving so He can steer us.But don’t mistake following joy for doing whatever makes you feel good. Joy, most often, does not involve immediate gratification — still, we do know what it is as if it’s programmed into us — Jesus did:looking to Jesus, the founder and perfecter of our faith, who for the joy that was set before him endured the cross, despising the shame, and is seated at the right hand of the throne of God. — Hebrews 12:2 ESV#7 Don’t Glorify Mankind — Glorify GodThis seventh entry is the most important. It is not only the last but also the first, the alpha and omega, the beginning and the end, and it should permeate our meditations through and through. As I pondered what it is to glorify God, I thought about what it is that we can offer Him. There’s not much. He already has everything. But there are three things we can offer that can only come from a willing heart.Thanksgiving makes us content. The greedy, grasping, get-ahead at whatever cost, human inclination is fairly quashed by thankfulness. Contentment brings forth peace and rest. It quiets our souls, and makes us appreciative for what we have, birthing in us an attitude of gratitude. If you’ve ever given gifts, you’ll note the difference between those who appreciated your generosity and those who treated your gifts as an entitlement or even with disdain, insisting that they deserved better. We always want to give more and better things to thankful, appreciative people. So does God. Be thankful. I have come to thank God not only for blessings of material things and fortuitous circumstances, but also for who He is and his marvelous attributes: Compassion; Patience; Mercy; Loving Kindness; Truth; Grace; and Forgiveness. I wake up thankful and find things to be thankful for throughout the day and I thank God at night as my head hits my pillow. I even thank God in my dreams! There are songs of thanksgiving that I sing just because I’m in the mood of being thankful. God likes this, I’m sure.Praise is simply extolling someone’s virtues. We praise children when they stand up and when they walk for the first time or when they say their ABCs or finish their first puzzle; it encourages them! We praise rookies when they start a new job. We praise sports teams on the field of play. We cheer, we chant, we sing, we praise our team, our school, our business, our family, our nationality, our race, even our gender! When we praise, it builds us up as well as the people we praise; it strengthens us and encourages us as it does them! “We’re number #1! Our team rules! Go, team, go!” The players on the field feel it tangibly, courage and hope stir in them — they rise to new heights — and the fans do too! It infuses us with hope and courage to do great things and breaks down barriers, both physical and psychological. That’s what praise does. Praise God. Praise God often and without ceasing! Shout unto God with a voice of triumph!Worship is an intimate expression of love, of adoration — like you would express to the one who has captured your heart. Worship is love expressed unreserved, unrestrained, without embarrassment or shame — in a word: shameless love. When you truly worship, you don’t care what anyone else thinks or how they might judge you — you only think of expressing your heart to the one that you trust and give yourself to with utter abandon. Nothing else matters. When you Worship, God reciprocates. You are not rejected. You know your love will be returned because you are truly loved with a love that is so high you can’t get over it, so low you can’t get under it, so wide you can’t ’round it — it rocks your soul. Worship with all your heart.Thanksgiving, Praise, and Worship are totally different things and they impact us in dramatically different ways. The benefits are amazing. Once someone grasps the importance and value of Thanksgiving, Praise, and Worship, they begin to unlock many secrets to drawing close to the Most High and together they constitute glorifying God.