First Lilies of the Spring by Jeanne van Gemert
Before the early March snowfall, Spring in my neighborhood was in fast forward mode. Daffodils were galloping, fragrant flowering apricot blossoms (prunus mume) had come and gone, cherry blossoms had faded and the daphne were just coming into their glory. The perfect and predictably ordered spring sequence was unfolding. As in the structure of a familiar symphony, you know that the violins will set the melody echoed first by the oboes, etc.
I often feel a structure unfolding as I sit to meditate. There is no other time quite like the beginning when I slide more deeply into myself. I begin to move into well-practiced territory where the doors, in sequence, start to soften and open.
On Friday in the woods by the creek I saw the first trout lilies begin their exquisite yellow blooms. Trout lilies have broad leaves like speckled green tongues that suddenly throw out winter’s brown floor – and I lost my balance. In a split second I was searching for tree buds, imagining the first tiny origami-shaped unfurling leaves. I imagined the pale green new leaves flooding the trees and I realized I’d been washed downstream. I was very far away from the present moment. So I stopped. Breathed. Breathed in the dark brown tree limbs just as they were. Stood in the cold quiet of the winter woods just as it was. I did slyly smile at the trout lilies but kept my feet firmly on the cold winter ground and carefully appreciated things just as they are.
Dharma and End-of-Life Caregiving by Dr. John Ruark
About twenty five hundred years ago, a spoiled young aristocrat named Siddhartha Gautama had a series of encounters with illness, infirmity, and death that shook his complacent world view to its core. This personal cataclysm eventually caused him at age 29 to abandon his comfortable life, including his wife and young son, in order to search for better answers than his current thinking could provide to the problem of human suffering.
Those of us who have been called to care for people dealing with serious illness, death, and bereavement are daily confronted with the very same awesome and painful realities about the human condition that sent young Siddhartha into his spiritual crisis. Since most of us probably lack the time and inclination to wander northern India for six years in search of answers, I am going to try to distil my best understanding of how the Buddha’s insights can be brought to bear on the problems of suffering that end-of-life caregivers encounter every day. The ideas and practices I present are the ones that have proven the most useful to me in confronting my own version of the challenges I have encountered in thirty years of work with the dying and grieving.
First, before I can be an effective caregiver for others, I have to understand MY suffering. An example of my suffering is when I am driving in my car, I have a sense for how fast I need to be going and how much space I prefer between my car and the others sharing the road. All too often, someone encroaches on that, say, by cutting me off or tailgating me or having the nerve to be blocking my way by preferring to go more slowly. The unpleasant feeling I have can range from irritation to rage depending on how egregious the violation of my sense of entitlement, my desire to have things the way I think they should be. I find driving to be my most reliable daily laboratory for trying to practice mindfulness, though I am embarrassed to report how often I lapse into reactivity, sometimes just in my thoughts, sometimes in my actions. (I am reminded of a bumper sticker that said, HORN BROKEN, WATCH FOR FINGER…)
Now, of course, I have other kinds of attachments that also bring joy as well as suffering — attachments to the people I love. Here is an interesting dynamic tension: on the one hand, I can at least theoretically avoid suffering by avoiding attachments. However, if I somehow manage to do that life looks pretty bleak. So, inevitably, if I love I also sign on for suffering, and to fail to love is to avoid the essence of what life has to offer. As Oliver Hardy often said to Stan Laurel, “Isn’t this a fine mess we’ve gotten ourselves into!”
But wait, it gets worse! The current unfortunate (perhaps) truth about our brains is that the part that makes us human is literally designed to form attachments. What was our Intelligent Designer thinking? If you look at the size of the forebrain in mammals, you will see that it increases in direct proportion to the complexity of the problem each species faces in finding prey and avoiding predators, or in other words, predicting the future. And the kinds of attachments that cause suffering are exactly that: predictions of the future. So no matter how hard we work at not forming attachments, we are pretty much hosed, since the instant we let down our guard, our brain is going to start doing what it was created to do.
The neurobiology of this process is dictated by a principle called Hebb’s Axiom, which stated over half a century ago: “Neurons that fire together wire together.” This simple concept has powerful consequences, since the more often we repeat a pattern of thought or action, the more hard-wired it becomes. Fortunately, the reverse is true as well: if we stop repeating a pattern it decays, and can be replaced by newer, more adaptive patterns if we diligently practice the new way of thinking and acting. For example, when I was addicted to tennis, I always wanted to hit a topspin backhand, and I attended a famous tennis teacher’s clinic to learn how. He got me up in front of the class had me close my eyes and take a backhand grip, turned the racket in my hand to an unfamiliar position, and asked me how it felt. I replied, “Crummy!”, and he said, “Get used to that crummy feeling, because you’re going to hit a thousand balls with it this week.” By the end of the week, I had a real topspin backhand, and another level of understanding of the old AA saying, “Fake it ‘til you make it!”
A growing body of evidence shows that somewhere around a thousand repetitions is required to replace an old neural network with a new one, so this kind of change is not accomplished overnight, but it can be done. And in fact, that is another thing that cutting edge neuroscience is at least hinting at (since the resolution and speed are not developed enough yet to catch individual neural networks as they are firing): a thought, or feeling, or action is actually a transient neural network, a group of around ten thousand neurons, often widely distributed in the brain, that fire simultaneously, and if they repeat enough times, actually register in consciousness. Daniel Siegel in The Mindful Brain looks at the neuroscience of mindfulness practice, and shows fascinating data about how meditation actually changes the way the brain is wired, away from primitive reactivity, and toward a more conscious higher level of functioning. For example, before I started meditating over a decade ago, I would have challenging moments during psychotherapy with difficult patients when I would become confused or reactive, and all too often would ‘shoot from the hip’ and say things I later regretted. After meditating a few years, I discovered that when I began to feel confused or emotionally flooded, if I centered my body in my chair and took a couple of mindful breaths, I would calm down and have a better chance of responding skillfully in a challenging moment, at least on my good days…
I think of meditating as a simple laboratory that eliminates as many outside distractions as possible from the task of observing what’s going on in my mind and body. Siegel makes the scientific point that meditation (along with yoga and tai chi in the studies he quoted or conducted) is an ‘integrative activity’ in the brain, activating higher and lower centers as well as both sides of the brain simultaneously. The more we do this, the more robust our powers of self-observation and self-intervention become., Then we are able to recognize dysfunctional reactivity as it is arising and redirect our thoughts and actions to more productive pathways. Interesting studies cited by Daniel Goleman in Emotional Intelligence show that a ten week mindfulness course enabled the fear reaction to a subliminally perceived threat to be diverted from its usual terrified reaction in the right brain to the less reactive left brain, thereby avoiding its previously induced panic response, all within 250 milliseconds.
A big part of what meditation practice teaches me is that I can tolerate challenging physical and mental states without getting caught up in an escalating panic, and that once I return my focus to the breath, unpleasant inner states are revealed as transient and insubstantial. This important realization, which needs to be reinforced literally thousands of times before it becomes strong enough to hold up during extreme stress and challenge, is the behavioral cornerstone upon which end-of-life caregivers can build their coping strategies for the overwhelming existential challenges we often have to face in our work.
Buddhist psychology and neuroscience does offer some practical help in coping with the impossibly challenging work of abiding with dying and grieving people through their difficult transitions. Let’s lay out the problem: the end-of-life situation is designed to evoke the deepest levels of reactivity and suffering for everyone involved, since it highlights many of our most cherished attachments. The dying person is losing everything precious to them: their health, their life, their freedom from pain, their most cherished activities and functions, their relationships, their world, and all too often, their dignity. Every incompletely grieved or worked through loss or trauma is likely to be re-stimulated at some point in the course of a terminal illness, and caregivers are there to support the dying and their loved ones and help them to maintain as much equanimity and grace as possible through these challenges. The families and support communities of the dying will likewise be confronted with endless similar variations of the challenges faced by the dying person, and they too look to caregivers as their guides for making it through these harrowing times with as little unnecessary suffering and as much of a chance to offer support for their loved one as they can.
In my experience, a guide has to lead the way through unknown territory, and though we may have traveled the harrowing path from diagnosis of a life-threatening illness through death and grief and mourning many times with our patients, familiarity alone will not suffice to make us the best possible guides. For the sake of our own mental health, which will be reflected in our ability to continue to thrive while doing this work with heart, each of us needs to have come to terms with illness, infirmity, and death for ourselves. If we have not done this serious emotional spadework, no matter how good our technique is, it will be prone to fail us when our own unresolved issues around loss or trauma get re-stimulated by what our patients and their families are facing. For example, my own early history is one of significant abuse at the hands of those who were responsible for caring for me. I have put in an embarrassing amount of couch time in therapy trying to lay those demons to rest, but most of my biggest mistakes as a psychotherapist still arise around that issue. Several weeks ago, a skilled and trusted supervisee of mine was presenting a case in which she got off center in working with patient who was just summoning up the courage to talk about something really shameful to him. In her rush to deal with her own anxiety about what he might reveal, she made a move that probably made it more difficult for him to tell his secret. I felt a sudden protectiveness of him, and an intense need for her to see and acknowledge her error, and lost my own awareness that my old wounds had been triggered. As a result, I was not as gentle with her as she needed and deserved, so actually repeated the very same error she had made, just by losing awareness of myself at a critical moment. I actually became the unkind parent, and had a good deal of repairing to do (i.e., crow to eat) to make it right.
What this rather embarrassing example illustrates is that even when we have put a lot of time and energy into facing our own issues, if we lose mindfulness they can still turn around and bite us (and those who depend on us). So now that I’ve made my case for mindfulness practice as a necessary vehicle for ongoing awareness of areas of challenge for each of us, let’s review a few specific issues that end-of-life caregivers would be well advised to work on and come to terms with.
The biggest emotional challenge faced as we confront death (or its early harbingers, the loss of cherished functions and relationships) is the inability to maintain our illusion of control. It is a big, dangerous universe out there, and the fantasy that we are in control of what does and doesn’t happen to us and those we love is extremely reassuring when Mother Nature is kind enough to leave us alone in the reverie that we have the power to keep ourselves and our loved ones safe. Life-threatening illness rudely interrupts that illusion, including for us caregivers, and the ability to notice that this has happened, and to practice consciously letting go and not trying to push the river, can allow us to be islands of equanimity when things get chaotic around us. If we stay calm and non-reactive, it is much easier for patients and families to calm down themselves.
An equally formidable emotional challenge that death demands that we face is the universal fact of impermanence. The Buddha described impermanence as one of the basic characteristics of worldly existence, and science has done nothing to contradict him in two and a half millennia. Everything in the world always changes if you adjust the time or physical frame of reference, even the molecules in our bodies, let alone those bodies themselves. One of the reasons Americans have become so materialistic as a death-denying culture is that our beloved possessions can allow us to hide in an illusion of permanence, believing that these houses and furniture and gadgets are going to last forever (though we have a so-called new washing machine at home that seems smugly dedicated to helping us to remember otherwise by breaking down every few months…).
My own body in its middle age has taken to reminding me constantly about this very issue, as pain-free life fades into distant memory and various cherished functions become steadily shakier. On good days I regard these little indignities as my teachers about facing death with equanimity, and on not-so-good days I have my own little personal pity-parties, though my pride and concern for my reputation leads me to mostly keep that whining to myself. I do recommend bringing consciousness to our private encounters with mortality as the best training ground for developing the equanimity to lend to our patients and their families as they face more immediate and terrifying reminders of impermanence. My own bad example notwithstanding, routinely sharing these feelings about our own fragility with sympathetic friends or colleagues can help our growth in this area. An anthropologist observing a tribe in the highlands of Papua New Guinea overheard a very wise statement from an aboriginal sorcerer to his frustrated apprentice: “There are no obstructions, only instructions.” Think about this when you feel thwarted; a famous local teacher of psychotherapy named John Firman put the same piece of wisdom in different words: “What’s in the way is the way.”
A final more specific difficult area that end-of-life caregivers constantly encounter is the loss of cherished relationship, both between our patients and their families and in our own lives. The Buddha said that nirvana was more difficult, if not impossible, to be achieved by householders (as opposed to monastics) in part because the deep interdependence between family members made it impossible to maintain equanimity in the face of losing beloved persons. Now, a cynic might wonder if he was post hoc justifying running off and leaving the wife and kid to wander around with his fellow seekers of wisdom, but I actually think he had a good point. Interpersonal neurobiology shows that deep relationship creates big changes in the brains of both partners (see Louis Cozolino’s The Neurobiology of Human Relationships), such that losing each other has devastating effects. The more deeply we love, the more intertwined our minds and brains become in relationship, and the greater the suffering we sign on for when inevitably one of us leaves the other. The fact that humans still choose to love in spite of an intuitive awareness of this truth is one of our most admirable and courageous traits, to my mind.
The way I work with this is in myself is to routinely (at least once a day) think about the loss of each of the people I love most dearly, to allow myself to sink into the terror and misery of that possibility (or shouldn’t I say, inevitability) for a bit. This quick trip through my own ultimate nightmare serves (on good days, as my dear wife would no doubt remind me) to sharpen my appreciation for those I love, and to lessen my tendency to take them for granted. And my little daily exercise in trying on my most feared losses actually seems to make me more open-hearted and equanimous with patients and families that are facing such grim realities not by choice. What my daily practice reminds me, and enables me to feel more comfortable reminding them, is that we are endowed with the mechanisms to get through the suffering of such losses, and return more quickly to normal life if we allow ourselves to feel and express the misery we must endure when a loved one dies.
Astute listeners will have noted a similarity between the techniques I am suggesting to deal with all three of the existentially most challenging aspects of end-of-life care: loss of the illusion of control, impermanence, and loss of cherished relationships. Like many other Buddhist techniques, it involves doing the opposite of what our primitive reactions advise us to do. This principle dovetails back into my initial discussion about how the nature of our minds causes us to suffer, such that around difficult issues it is often more skillful in the long run to do the opposite of your first instinct. All of our initial impulses around painful topics are to avoid them, sort of like the old joke about the patient coming to the doctor saying “Doc, it hurts when I do this,”, and the Doctor responding, “So don’t do that!” Many Buddhist teachers and authors discuss this tendency, and Pema Chodron (one of my favorites) calls it ‘leaning in’ to painful issues. I like that metaphor, since it seems more feasible to the less brave side of me than ‘diving in’ when something seems barely tolerable to think about, let alone embrace. The next time you encounter a place that scares you, instead of avoiding it, try mindfully leaning into the painful issue, especially in dialogue with someone wise and supportive, and you might be surprised at how much you learn and grow.
I would like to end by expressing my admiration and appreciation to all who choose this courageous but difficult pathway for their life’s work, and my wish and conviction that in the long run karma will see to it that the good they do for some of the most vulnerable members of our society will reflect back powerfully into their own lives.
Each Breath by Carolyn Dille
Reflections on Channel Surfing by Lynn Sunday
My husband Lee and I almost came to blows in our living room last week over his love affair with the channel selector. It was an old issue between us and we skirted dangerously close to ending up in couples counseling over it, but finally, some changes were made.
What happened was I joined Lee and our dog Hootie on the couch in front of our big, flat screen TV in anticipation of Bill Maher’s: Politically Incorrect. We snuggled comfortably with Lee’s arm around me, my head on his shoulder, and Hootie’s little head resting on my curled-up legs. The show began and was laugh-out-loud funny. I was enjoying myself. At the first commercial break, Lee grabbed the remote and began channel surfing.
Question: is the channel selector just one more thing in this world for the male animal to explore and take charge of?
Anyway, the instant the commercial break came on, my generally considerate husband went through some kind of metamorphosis; his channel selector finger got itchy and away we go; surfing’s the name of the game! Click! We’re watching a scene from a love story that moved me to tears; then are treated to a selection of details from a police report on serial killing. Nice. Click! Click! A fleshy woman in pink is sautéing shrimp with garlic; four fifty-something’s are back packing, gaily, through Eastern Europe; five expressionless people stare at their cards during a tense moment in an international Poker championship. Click! We’re in the middle of a bloody fight in an exciting film preview that Lee saw two nights ago—at full volume.
By the time he returned to Bill Maher, the show was already in progress, the audience was convulsed with laughter over what funny line I would never know. Now to me, TV commercial breaks are inherently evil and should never be dignified by being watched by anyone. That’s what mute buttons are for, with time spent productively, in peaceful silence, fetching drinks and munchies, visiting the bathroom, or even, as I told Lee snidely that night, for actually talking to each other.
“Will you please stop jumping from channel to channel?” I demanded nastily, turning to face him. “You do that every time we watch TV. It drives me nuts!”
Looking back on it I could have made my needs known more diplomatically, but despite the series of cool talks by my yoga instructor, Gail, regarding the maintaining of equanimity within—regardless of circumstances without—those were, unfortunately, the words I used. Consequently, a rather stupid argument ensued with each of us biting down on our respective positions, like Hootie bites down on a bone.
“Why does it bother you so much?” Lee asked, annoyed. “I was curious about what else was on. I was exploring. Can’t you just tune it out?”
“Why should I tune it out?” I asked righteously, glaring at him. “Why can’t we have silence during the breaks? What would be wrong with that?”
The argument continued. I, somewhat pompously, stressed the physical, emotional, and spiritual benefits of meditative silence. Lee rose to the occasion and defended, with vigor, his apparently inalienable right to the extremely, annoying activity of channel surfing—which I have no doubt, comes with being born male.
We watched TV again a few evenings later, Boston Public was on. With the air of a martyr about to be set on fire, Lee muted the commercials and without once touching the channel selector, sat silently through each break. He didn’t even click on the sound for a preview of a new show we hadn’t seen yet. He didn’t say a word, but I could feel his pain.
I have to say the silence was enjoyable, but somehow I didn’t feel good about how pushy I’d been about getting my way. “Look, that’s a preview for a new Clint Eastwood film.” I told Lee. I ruffled his graying hair fondly as I got up from the couch. “You haven’t seen that one yet. Why don’t you turn on the sound and check it out while I get us some desert?”
The moment I left the room I heard Clint’s voice as the preview came on, then the familiar click of the channel selector, followed by the sound of sirens, a woman screaming, and finally, a dog barking. At the blue tiled counter in our kitchen I sliced German Chocolate cake and scooped strawberry ice cream on top. When I returned to the living room with dessert, Lee—a happy man—was surfing channels rapid fire, like it was something he was born to do. “Does this really bother you?” he asked a little plaintively.” I can turn it off…..”
Loving him, I shook my head no and remembering to breathe and remain calm, I sat down beside him and offered him cake. Images whizzed by me like some psychedelic
dream sequence, but this time I put Gail’s words of wisdom to practice and focused my attention on my breath. Surprise! I wasn’t irritated. I wasn’t annoyed.
Channel surfing, I decided, may not be the finest of Lee’s masculine qualities, but does appear to be part of who he is, so my best move is to live and let live. Click! Someone on a reality show was chomping down on an insect the size of Rhode Island. I closed my eyes and breathed deeply, in and out, in and out; then I opened them and smiled at Lee. For this moment, at least—and the moment, I understand, is all there is—I have achieved some measure of acceptance, maybe even equanimity.
The Dusty Road by Susan Ezequelle
So many travelers on a dusty road,
Walking, searching, wondering,
What is Truth?
These are the Seekers.
Out of the dust
Towns spring up along the road.
Houses secure, doors locked.
These are the Believers.
Wanderers seek Truth in spaciousness,
The blue sky in Autumn.
Believers look for something closed.
The mole hole in the garden.
Truth asks for a soft touch,
Carry it lightly in an open palm.
Belief demands clutching.
Grasp it, get a firm grip.
Truth turns its face from nothing.
The wondering gaze of a young child.
Belief bears a rigid countenance,
Fixed stare, frozen as a statue.
Truth welcomes all travelers,
A gracious generous host.
Knock on Belief’s door,
It may shut in your face.
Truth has an open heart,
There’s nothing to hide.
Belief is furtive, careful where it steps.
A fragile shell can be broken.