Some years ago, I was asked to address a group of community clergy regarding death, dying and end of life care. In the course of my lecture, I indicated that this topic is mostly taboo from a pulpit because the clergy themselves struggle with a sense of self death-awareness. Most in the audience agreed. As I continued, focusing one how our public prayers contain many references to death and life after death. We can say the words in prayer, but to have intention and meaning in those words tends not to be emphasized.
A short piece, Religion, patients, providers, was published describing the value of religious leaders having end-of-life discussions. While it is unfortunate that the article doesn’t discuss the importance of how chaplain/spiritual care providers can be a resource for this discussion, it is encouraging to see the increase in confronting the realities of life in religious communities.
Religion, patients, providers
By Eliza Blanchard
Published 8:13 pm, Friday, December 2, 2016
Talking about death is a daunting topic, and we applaud the growing number of congregations that are giving their members tools and resources to have conversations with their families and loved ones around end-of-life preferences.
But as important as these discussions are, it is also crucial that health care providers are prepared to have end-of-life conversations with patients, especially when religion plays a role in the patient’s decision-making.
In the United States, where 78 percent say religion is important to their lives, it will inevitably emerge in health care. A study found 41 percent of patients thought of a time when religion influenced one of their health care decisions. Its impact might be patients needing a kosher, halal or vegetarian hospital meal or requests to coordinate medical procedures around prayer times.
The most profound intersection may be in end-of-life care. Religion can influence the procedures patients want to receive, or reject, such as starting artificial respiration or removing this support once it is in place. Religious beliefs may affect patients’ beliefs about the afterlife and help frame their illness in a context that medical professionals need to understand.
Yet health care providers are often ill-equipped to discuss religion when it does come up, with one study finding that one in five medical residents reported being unprepared to care for patients whose religious beliefs affected their treatment. This discomfort means that important conversations about how religion affects patients’ end-of-life decisions simply never happen.
Medical students, residents, nurses and nurses’ aides need training that goes beyond a one-off course in cultural competence. They need expertise in taking a spiritual history as a routine part of taking a patient’s history.
Even when patients don’t know right away what their care might entail or how religion may be relevant for them, asking these initial questions can open the door to further conversations and make the patient more comfortable voicing their beliefs if and when they become relevant. The result can lead to better care every day, and certainly as life draws to a close.
Clinicians need to learn to recognize signs of spiritual distress so they can refer patients to pastoral care for spiritual support and guidance. These should be skill sets that we expect from our providers and that they are trained to execute.
Today, more and more organizations and communities, including religious communities are promoting open, honest and proactive conversations around end-of-life preferences.
As that trend continues, it is important to ensure that health care providers need know to ask about a dimension of many people’s lives that influences their choices, and then incorporate their patients’ religious beliefs and practices into a plan for care.
Anyone who has trained to offer mental health, spiritual, or psychosocial care knows that part of the training process in coming to a greater understand of oneself. It is important as self-knowledge can help each of us understand those things that trigger adverse reactions and learn how to both recognize and work within those triggers. The same holds true for all life’s relationships. In the following article, the authors describe the value of self-knowledge in our personal relationships as well.
One goal common to many types of psychotherapy as well as psychoanalysis is to learn about yourself, who you are (your inner self and outer self) at present and how you got there.
Yet knowing yourself may be one of the hardest tasks you’ll ever attempt.For many of us, a myriad of obstacles spring up when we attempt it.
If you tend to be intellectual or philosophical, you might get mired in questions such as: “Who is the me/self that is assessing the me/self?”
If you tend to be emotional, you might get bogged down in less-than-positive emotions around the issue.
If you are more likely to be spiritual, questions such as “Why am I here” or “Why was I created” can sometimes stymie self-knowledge.
But knowing yourself is important to all your relationships, helping you fine tune your sense of humanness.
Parents and Kids
Effective parents, for example, know themselves. Self-awareness without self-centerdness, is an important ingredient in any relationship but essential to healthy parenting.
In order to deeply understand what your child needs, to really “get” where your child is coming from, and how he experiences the world around him, it’s essential that you know who you are: what makes you tick, what brings you down, what uplifts you, what turns you off.
When we know who we are, we are more open to seeing beyond the surface in others.
But in order to understand who we are, we have to take the time to do so. By learning more about who you are and how you feel about yourself, your child, and life in general, you’ll be able to interact more effectively—and lovingly—with your child.
—From The Parent-Child Dance: A Guide to Help You Understand and Shape Your Child’s Behavior by pediatric behavioral specialist Miriam Manela, OTR/L and C.R. Zwolinski (PsychCentral’s Therapy Soup)
One of the most important things I’ve learned while working on The Parent-Child Dance with Miriam, is that in any relationship, having an appreciation for who you are and an understanding of how you “take in” the world, how you experience life, really makes a difference to how you relate to others.
Seems obvious, doesn’t it?
But sometimes you have to hear an obvious fact over and over again before it sticks.
You have to know what makes you tick, in order to find satisfying work. You also need to have an appreciation of what makes others tick, in order to create satisfying work relationships. This can be on the smaller scale, for example, you don’t need to know everything about that person in another department who you meet once a month, but knowing the person you are teaming with on a project can be vital.
Coworkers get together after work to relax and unwind, but this is the best time to pay attention and really listen to your coworkers. You may see a sense of humor you’ve never noticed before, or learn about the personal pressures they are under. Carry your knowledge through to your work relationship so you can be supportive, as well as tap into their talents and interests.
Friendships and Personal Relationships
Sometimes, we can be a little obsessed with having our own needs met. And sometimes we can push our own needs to the background, so much so that we forget who we are. Striking that balance requires paying attention and learning all the ways in which you cope, deflect, or deny.
Knowing yourself doesn’t mean that you cannot change yourself. You have to know yourself well enough to sense whether change will enrich your relationships, emotional well-being, and life in general.
Richard Zwolinski, LMHC, CASAC is the author of Therapy Revolution: Find Help, Get Better, and Move On Without Wasting Time or Money and is an internationally licensed psychotherapist and addiction specialist with over 25 years experience as well as a consultant to organizations and companies in the fields of mental health and addiction. Learn more about Richard here.
I find death reflection to be a very honest look at living. While it is only a microcosm of the mindset of the dying, reflecting on what it means to have limits to life is a valuable exercise. The following is one person’s death reflection looking at meaning in life after experiencing multiple deaths in the first week of 2015.
“Go confidently in the direction of your dreams. Live the life you have always imagined.” — Henry David Thoreau
“No, there have been four deaths,” my mom’s husband corrected me. “Your cousin’s mom died yesterday.” Talk about a grim way to start off the New Year. The man who lived across the street from my mom, the elderly lady my mom cared for years ago, my brother’s friend’s wife — she was only 32, four years younger than I am — and now my aunt. How is that for the first week of 2015?
The interesting thing about death is that if we’re not “old” or in poor health, it isn’t something that is at the forefront of our mind. Meaning, we think we have plenty of time. It’s this false sense of time that keeps us in jobs we’re unhappy with for a decade or in passionless relationships or from chasing our dreams.
Five years ago my brother’s friend Jona found out he had a rare form of cancer and within a few weeks he passed away. Jona documented his last six weeks in a blog — prepare to shed some tears. He was only 27. What would you do if you knew you only have six weeks left to live?
To have four people within my extended circle of family and friends die within the same week, made death feel not only inevitable, but closer to home. Regardless of how much or little time we have left, here are four things death teaches us about life.
“It often takes suffering and lost in order to remind us of how precious life is.” — Rob Bell
1. Our time is limited. Whether we live to be 27 years old like Jona or we live to be 107 years old, until science is able to figure out a way to make us live forever, one day our life on this planet will come to an end. Meaning, that we don’t have time to wait to take that trip to Italy we’ve been dreaming about the last few years or to start a business or to spend more time with our family because, like it or not, the clock is ticking. So how do you want to spend your precious days or weeks, or even minutes?
Six months ago while in France, I had a brush with death when a motorcycle nearly ran me over. That was enough to make me speed up the changes I was considering making at the end of the year. I’ll just give it a few more months and see, I kept thinking, when in fact I already knew what needed to happen and was basically procrastinating.
2. Follow our heart. As Steve Jobs so famously said, “Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.” I know it can be scary chasing after our dreams, ask anyone who has tried, myself included. Following your heart, following your passion, dreaming big is not easy, because if it were everyone would be doing it. But, here’s the thing, would you rather live a life of What ifs? or a life of I’m going for it!
“You are never too old or too broken. It is never too late to begin, or to start all over again.” — Bikram Choudhury
3. Second chances. Life is all about second chances. Bikram Choudhury, the founder of Bikram Yoga said “You are never too old or too broken. It is never too late to begin, or to start all over again.” Each day, each breath, each moment is an opportunity for us to try again, a chance to create the life we truly want and to go after our dreams. When was the last time you asked yourself, Am I living the life I really want? If the answer is no, then maybe it’s time to figure out what you can do to change it.
4. The present moment. Now is the only guarantee we have. Now is what matters most in life. In the Power of NOW, Eckhart Tolles says, “Realize deeply that the present moment is all you have. Make the NOW the primary focus of your life.” Although some things take time and cannot be created overnight, the now is where the miracles happen. Now is when we have the opportunity to experience the intricate details of life. However, to fully experience the joys of watching your child take their first step or the majestic Na Pali coast, it is important for us to be fully present, to live in that space of wonderment where life is currently happening.
Current understandings of grief has shifted away from looking at grief as a continuous upward process through stages and instead looks to how individuals integrate loss into their lives. In the following description, we see how misperceptions of grief can be a hindrance for people, as the expectations of moving through grief are often unrealistic. With these misperceptions, when grief doesn’t move forward, people often get increasing anxious and concerned, and a vicious cycle begins. In the bereavement group I co-run, we had a person attend who shared she hadn’t cried for her husband for many months and worried something was wrong. We discussed how tears come for people at different times and in different situations. In a subsequent meeting, she shared that she had finally cried, as she was no longer trying to force herself to shed tears, the tears came.
By PATRICK O’MALLEY JANUARY 10, 2015 1:16 PM January 10, 2015 1:16 pm
By the time Mary came to see me, six months after losing her daughter to sudden infant death syndrome, she had hired and fired two other therapists. She was trying to get her grief right.
Mary was a successful accountant, a driven person who was unaccustomed to being weighed down by sorrow. She was also well versed in the so-called stages of grief: denial, anger, bargaining, depression and acceptance. To her and so many others in our culture, that meant grief would be temporary and somewhat predictable, even with the enormity of her loss. She expected to be able to put it behind her and get on with her life.
To look at her, she already had done so. The mask she wore for the world was carefully constructed and effective. She seemed to epitomize what many people would call “doing really well,” meaning someone who had experienced a loss but looked as if she was finished grieving. Within a few days of the death of her daughter she was back at work and seemed to function largely as before.
The truth of her life was something else. Six months after her baby’s death she remained in deep despair. She was exhausted from acting better than she felt around co-workers, friends and family. As is so often the case, she had diagnosed her condition as being “stuck” in grief, believing that a stubborn depression was preventing her from achieving acceptance and closure.
Was she in denial, she wondered. She also wondered if she was appropriately angry. The bottom line was that she knew she was depressed — a psychiatrist had prescribed an antidepressant — and that is what she wanted me to treat.
Earlier in my practice, I would have zeroed in on that depression. Was there a family history? Had she been depressed before? Was the medicine helping? What were her specific symptoms? Knowing the answers might suggest why she was stuck. Or I would have reviewed the stages of grief, as she had, looking for one in which the work remained incomplete.
But I had begun to operate differently by the time Mary showed up, which was 10 years after my own loss. My firstborn child had also died before he was a year old. It was why Mary had chosen me.
In our first session I put Mary’s depression aside. I asked her to tell me the story of her baby rather than describe the symptoms of her grief. Though she was resistant, she eventually started to talk.
Like most other things in Mary’s life, the baby, whom she named Stephanie, was planned. Mary was delighted with her pregnancy and had wonderful dreams for her daughter. After a routine delivery, Mary stayed home with Stephanie for the first three months. Returning to work had been difficult, but Mary was comfortable with the child-care arrangement, and managed to balance motherhood with her busy professional schedule.
Then Mary told me about the Saturday when she went to check on her napping daughter and found that Stephanie wasn’t breathing. She began C.P.R. as her husband called 911. There were moments of surreal focus as she and her husband tried to save their baby. Then this woman, so accustomed to being in control, had to surrender her daughter to an emergency crew. Her husband drove as they followed the ambulance to the hospital.
She described the waiting room in great detail, down to the color of the furniture. When the hospital chaplain walked in with the doctor she knew her baby was gone. She and her husband were taken into a room where they held the baby for the last time.
At this point in her story Mary finally began to weep, intensely so. She seemed surprised by the waves of emotion that washed over her. It was the first time since the death that the sadness had poured forth in that way. She said she had never told the story of her daughter from conception to death in one sitting.
“What is wrong with me?” she asked as she cried. “It has been almost seven months.”
Very gently, using simple, nonclinical words, I suggested to Mary that there was nothing wrong with her. She was not depressed or stuck or wrong. She was just very sad, consumed by sorrow, but not because she was grieving incorrectly. The depth of her sadness was simply a measure of the love she had for her daughter.
A transformation occurred when she heard this. She continued to weep but the muscles in her face relaxed. I watched as months of pent-up emotions were released. She had spent most of her energy trying to figure out why she was behind in her grieving. She had buried her feelings and vowed to be strong because that’s how a person was supposed to be.
Now, in my office, stages, self-diagnoses and societal expectations didn’t matter. She was free to surrender to her sorrow. As she did, the deep bond with her little girl was rekindled. Her loss was now part of her story, one to claim and cherish, not a painful event to try to put in the past.
I had gone through the same process after the loss of my son. I was in my second year of practice when he died, and I subsequently had many grieving patients referred to me. The problem in those early days was that my grief training was not helping either my patients or me. When I was trained, in the late 1970s, the stages of grief were the standard by which a grieving person’s progress was assessed.
THAT model is still deeply and rigidly embedded in our cultural consciousness and psychological language. It inspires much self-diagnosis and self-criticism among the aggrieved. This is compounded by the often subtle and well-meaning judgment of the surrounding community. A person is to grieve for only so long and with so much intensity.
To be sure, some people who come to see me exhibit serious, diagnosable symptoms that require treatment. Many, however, seek help only because they and the people around them believe that time is up on their grief. The truth is that grief is as unique as a fingerprint, conforms to no timetable or societal expectation.
Based on my own and my patients’ experiences, I now like to say that the story of loss has three “chapters.” Chapter 1 has to do with attachment: the strength of the bond with the person who has been lost. Understanding the relationship between degree of attachment and intensity of grief brings great relief for most patients. I often tell them that the size of their grief corresponds to the depth of their love.
Chapter 2 is the death event itself. This is often the moment when the person experiencing the loss begins to question his sanity, particularly when the death is premature and traumatic. Mary had prided herself on her ability to stay in control in difficult times. The profound emotional chaos of her baby’s death made her feel crazy. As soon as she was able, she resisted the craziness and shut down the natural pain and suffering.
Chapter 3 is the long road that begins after the last casserole dish is picked up — when the outside world stops grieving with you. Mary wanted to reassure her family, friends and herself that she was on the fast track to closure. This was exhausting. What she really needed was to let herself sink into her sadness, accept it.
When I suggested a support group, Mary rejected the idea. But I insisted. She later described the relief she felt in the presence of other bereaved parents, in a place where no acting was required. It was a place where people understood that they didn’t really want to achieve closure after all. To do so would be to lose a piece of a sacred bond.
“All sorrows can be borne if you put them in a story or tell a story about them,” said the writer Isak Dinesen. When loss is a story, there is no right or wrong way to grieve. There is no pressure to move on. There is no shame in intensity or duration. Sadness, regret, confusion, yearning and all the experiences of grief become part of the narrative of love for the one who died.
Patrick O’Malley is a psychotherapist in Fort Worth.
This is an essay from Couch, a series about psychotherapy at nytimes.com/opinionator. Some details have been altered to protect patient privacy.
There was a great article I saw from a physician describing his feelings towards prayer being important in his medical practice. He shares two stories about situations in which through praying, there was guidance in advancing the medical help. I was particularly taken by his candidness in acknowledging that his prayer was just a “simple plea for help.” I would offer that prayer is just that. Prayer can be beautiful and poetic. But prayer from the depths, from the heart, is often plain, ugly and brutish. It is the simple musings we feel.
As a physician I am often reminded of two things for which I am grateful. First, the great honor it is to care for people who are in a time of great need in their lives. Second, the many mentors in my life who have patiently taught and trained me in the arts of medicine.
Recently, I have thought a lot about one mentor, the late Dr. Blayne Hirsche. Dr. Hirsche was a gifted plastic and hand surgeon. He trained in surgery at Harvard and the Mayo Clinic. He founded the Hirsche Smiles foundation, which has performed thousands of reconstructive surgeries on children in Mexico and Guatemala. His legacy of compassionate care and service lives on through this foundation.
A Young Surgeon’s Prayer
Before medical school, I had the pleasure of working with Hirsche to gain experience as he performed surgeries. I cannot recall the details of why, but one day we talked about lessons he had learned during his training. One story he told has stuck with me ever since. He talked about a difficult surgery he was performing as a resident physician at Harvard. The head surgeon was world-renowned for the procedure being performed. Unfortunately, severe abdominal bleeding complicated the surgery.
At one point, it became apparent to Hirsche that the patient was going to bleed to death. Blood would rapidly fill the open abdomen as quickly as the surgical team could evacuate it, making it impossible for them to find the bleeding source. Suddenly the room became quiet and all eyes were directed toward the lead surgeon, who had stopped talking and working. A few moments later the surgeon reached into the abdomen and the bleeding stopped. His fingers had found the bleeding source, and with pressure the bleeding stopped. With the bleeding source identified, the surgeons quickly sutured the area, and the patient lived.
After the surgery, Hirsche asked the lead surgeon what had happened and why had he stopped. The lead surgeon said he stopped when he realized they were going to lose the patient, and he prayed for help. The surgeon did not say anything more. This was a profound experience for Hirsche as this surgeon was not known as a spiritual person. In fact, this was the one and only spiritual statement this surgeon ever made to Hirsche.
A Young Mother’s Difficult Heart Procedure
Most physicians are very aware of the limitations of medicine and medical procedures. Despite our best intentions, we often lose the battle to diseases. Every patient is unique, and even routine procedures can be challenging. All physicians who treat life-threatening diseases and have been in situations where they know they’re doing all they can for a patient and yet the patient’s life is slowly slipping away.
Hirsche shared his story with me nearly 20 years ago. His message found its way into my practice recently. A young mother of four children came to the hospital in severe heart failure. Four weeks earlier she had delivered a healthy baby. Now her heart was failing as 90 percent of the pumping function was no longer working.
As her heart failed, her lower heart chambers dilated and stretched, causing abnormally fast heart rhythms to develop. This further worsened her heart failure. Strong intravenous medications were started to support her blood pressure and fight impending kidney and respiratory failure. Despite our strongest intravenous medications to make the heart beat normally, as well as multiple electrical shocks to her heart, her abnormal heart rhythms continued.
It was clear she was close to dying, but we had a few options. One was to replace the heart with an artificial heart until she could get a heart transplant. Another option was to do open heart surgery to place heart pumps, called ventricular assist devices, to support her failing heart. The third was to go into her heart through her blood vessels, find the source of the abnormal heart rhythm, and destroy it. This could allow the heart to slow down and hopefully recover. Due to potential challenges with placing a heart pump, the third option was felt to be the best. For that reason, I became involved.
A Simple Plea for Help
When she arrived in our cardiac catheterization room, she was placed on a breathing machine. The room buzzed with physicians specializing in high-risk anesthesia, critical-care medicine, heart failure, and surgery. The cardiac surgery team was on standby to perform an emergency procedure, if needed, to transition her to a transplant. As we prepared for the cath procedure, her blood pressure continued to fall, requiring more medications to support it. Her blood oxygen level also started to fall, despite respiratory support. I quickly gained access to her blood vessels. In the setting of severe heart failure, these ablation procedures to treat abnormal heart rhythms often take four to six hours. I knew she didn’t have that much time.
Before I advanced the tool into her heart, I prayed silently. My prayers are not graceful and eloquent. I would characterize them as a simple plea for help. A few seconds after my prayer, I advanced a tool into her heart to the area I thought was most likely causing the abnormal rhythm. As the tool touched this area, the abnormal heart rhythm stopped. We delivered heat energy to the site to destroy the short circuit. Her blood pressure and blood oxygen began to rise. And her heart rate — once at 150 to 160 beats per minute — now beat normally at 100 beats per minute.
I have treated hundreds of these abnormal heart rhythms, but I have never seen such a quick response. Within five minutes of starting the procedure, her heart was normal. That night I was able to talk with her. She held my hand and said “Thank you.” There was not a lot more to say. It was humbling for me because I realized that a few hours earlier we both had pleaded for help. I am happy to report she is on her way to recovery. Her heart is getting stronger each day.
Faith and Hope Among Physicians
I have had many mentors who draw great strength from spiritual sources. Some have been Christians like me, while others were Jewish, Hindus, Buddhists, and Muslims. That is one of the great aspects of medicine: A tremendous diversity of backgrounds come together for a common goal. I have heard some people say that physician spirituality is a sign of weakness, but I have found the opposite to be true. These mentors of mine are world leaders in their fields and draw from all means to treat and care for people in a field that does not have all the answers. They use their faith to find inner strength and peace. To a believer of spiritual things these stories can make believing easier.
It is harder when prayers and best intentions fail. Believers will often say that when this occurs it is part of a greater plan or design. To a nonbeliever of spiritual things, perceived failures make it easier not to believe.
I am grateful for my patients who have told me that they, their family, or pastor have prayed for me and they believe everything will be all right. These gestures are filled with great faith and hope. Hope and optimism, regardless of belief, are associated with better outcomes and longevity. I once had a Catholic patient who came in for a very small routine procedure. He also took my hand and said, “It will be alright, I had my last rites read to me.” I am not sure if that was a vote of confidence. I told him thank you, but I was not planning on letting him die just yet.
I have a close friend who is an atheist. He told me one day, “You know all of this is not going to matter in the end, as we all die and aren’t coming back.”
I told him that is what makes it even more meaningful. Because when we do die, it is important to have hope in a better tomorrow.
In my work with seniors and people diagnosed with a terminal illness, there is tremendous mystery regarding the experiences of aging and loss. The health care system dynamics are fraught with twists and turns that most of us are not equipped to handle. As people are working to navigate through the stages of health care, many losses will inevitably occur. People experience emotional loss, feeling a sense of no longer being themselves. And the family of the older adult or terminally ill suffer emotional turmoil from witnessing the losses the other feels.
Much has been written to try and help others navigate the system. However, as the system constantly evolves, the writing from even a few years ago can contain much that is outdated. A recent book, Being Mortal: Medicine and What Matters in the End, by Atul Gawande M.D., attempts to offer guidance from someone on the inside. His work takes readers on a journey of aging and end of life care through personal stories of people the author knew from his medical world and his personal world, including his father, whose dying he describes using both his professional and personal eyes. Gawande offers readers what he sees to be innovation around senior health facilities and residences, about offering dignity in whatever way is possible in the midst of decline and how we are all fighting a battle medicine cannot win, namely death. The book is a personal testimony of a doctor discovering a world beyond medical procedure for curative means.
While his book is well written and reads smoothly, I would like to also offer a couple of critiques for what I see would have enhanced his presentation. As he is a doctor, focusing heavily on physical healing, I think he sometimes glosses over the holistic aspects of care that he is trying to promote by not including more disciplines in his presentation. For example, in his conversation about hospice, he follows a hospice nurse, the case manager, to see how she works with a terminally ill person but we never see the rest of the hospice team. While he does inform his readers that hospice care offers psychosocial and spiritual support through Social work and chaplaincy, he doesn’t show us what that would look like. The same is true in his analysis of senior housing facilities. While reading about the place in upstate NY that innovated with offering residents pets to care for, I felt he narrows the focus of dignity to giving people a sense of responsibility and purpose. My experience has been offering people connection to faith and spirituality can also play a major role in reviving selfhood and dignity.
Even taking the above into account, I found this book engaging on many levels. As someone in the field of senior care and hospice care, his descriptions offered me much to consider in my professional role in caring for people. As a human being who has and will experience various aspects of life, I think his work reminds each of us that we need to be aware of the power of change, both good and bad, as we age and the one’s we care for age. There is no escape but there are ways to bring respect and dignity to our interactions with family and friends going through these stages of life.
As the author below indicates, we often look for instantaneous results when we try and change. While the reality is that true change is long and arduous, with many setbacks, perhaps we can start with some of the advice offered below.
Traditional psychoanalysis has the patient coming to treatment three to four times a week, lying on a couch and free-associating to whatever comes to mind.
The theory behind this treatment is that free-association increases awareness of what is in the unconscious mind. Once you make the unconscious conscious, patients should, theoretically, become less neurotic.
That type of treatment seemed to work well for the idle rich in the late 19th and early 20th centuries.
But does it work well in the digital era?
No way. We want our problems solved quickly. We want solutions to be provided speedily. We savor the power of parsimony. The fewer the words, the more we value them. Short, sweet and to the point is preferable.
Is it possible to take the wisdom of Freud and apply it to the Twitter generation? I’m going to give it a shot. Here goes:
Quit comparing yourself to the best. You don’t have to be the best to make a valuable, worthwhile contribution to the world.
Don’t belittle yourself. Quit calling yourself derogatory names. Laugh good-naturedly at your mistakes, but don’t denigrate who you are and what you’re about.
Avoid sitting on the sidelines, bemoaning your circumstances without taking any action to improve your lot in life.
Even the best ideas are worthless unless you use your energy to execute them.
When you’re overstressed and overworked, take a break. Rest. Relax. Enjoy. Be with optimistic people. Then, get back to work.
Tolerate disappointment. There are days in which nothing works out well. This is a “bad day.” Don’t make it into a life position.
Allow your interests to emerge in their own way. Don’t attempt to make them fit into the box you (or others) think they should fit into.
Because a decision didn’t work out as expected doesn’t necessarily make it a bad decision. Reflect on what went wrong, however, before you move on to your next decision.
Acknowledge what you experienced in your early years. But put your energy toward living in the present where making good decisions can truly enhance your life.
Keep doing what you enjoy doing even if there’s no immediate reward to it.
When you believe in yourself, it’s amazing what you can accomplish.
Success is not an overnight happening. It’s the result of a consistent, driving energy that keeps you engaged, focused and moving forward.
Well, there it is. A dozen pieces of advice — short and succinct. Freud would appreciate, maybe even envy them.
Will just reading this advice allow you to make dramatic changes in your life? I doubt it. Freud was right. It takes time to change ingrained ideas and tenacious habits. But does it take as much time as Freud believed? Absolutely not!
Our sense of time is dramatically different than it was for people who lived 100 years ago. A few months of therapy once a week or even bi-monthly can help people truly change the direction of their lives by clarifying their thoughts, modifying their emotions and expanding their options.
And long-term therapy (still only once a week) is an amazing experience that can transform a life — from one that’s plagued with stress, tension and negativity to one that’s enriched, energized and full of enthusiasm.
Dr. Sapadin is a psychologist and success coach who specializes in helping people overcome self-defeating patterns of behavior, particularly debilitating fear and chronic procrastination. She is the author of 6 self-help books that have been published in 6 countries. Dr. Sapadin has been honored with “Fellow” status by the American Psychological Association, an indication that her work has an international impact on the field of psychology. Visit her website at www.psychwisdom.com. Contact her at LSapadin[at]DrSapadin.com. To learn more about her books on overcoming procrastination, visit http://www.BeatProcrastinationCoach.com.
Meditation is seen as a universally based method of spiritual growth. And while this is clearly the case for most people, even something seemingly as important and powerful has a dark side. The article below was an eye opener to me, not so much about the dark side but as a reminder that spiritual practice needs guidance. Practicing without safeguards can be a precursor to emotional and psychological danger. In Jewish tradition, we have an ancient idea from the book Ethics of Our Fathers that a good practice is to “make a rabbi for yourself.” I have always thought this was something beyond finding someone to direct you in what to do. It is also a warning to have someone to bounce one’s experiences off of who is potentially more experienced.
Set back on quiet College Hill in Providence, Rhode Island, sits a dignified, four story, 19th-century house that belongs to Dr. Willoughby Britton. Inside, it is warm, spacious, and organized. The shelves are stocked with organic foods. A solid wood dining room table seats up to 12. Plants are ubiquitous. Comfortable pillows are never far from reach. The basement—with its own bed, living space, and private bathroom—often hosts a rotating cast of yogis and meditation teachers. Britton’s own living space and office are on the second floor. The real sanctuary, however, is on the third floor, where people come from all over to rent rooms, work with Britton, and rest. But they’re not there to restore themselves with meditation—they’re recovering from it.
“I started having thoughts like, ‘Let me take over you,’ combined with confusion and tons of terror,” says David, a polite, articulate 27-year-old who arrived at Britton’s Cheetah House in 2013. “I had a vision of death with a scythe and a hood, and the thought ‘Kill yourself’ over and over again.”
Michael, 25, was a certified yoga teacher when he made his way to Cheetah House. He explains that during the course of his meditation practice his “body stopped digesting food. I had no idea what was happening.” For three years he believed he was “permanently ruined” by meditation.
“Recovery,” “permanently ruined”—these are not words one typically encounters when discussing a contemplative practice.
On a cold November night last fall, I drove to Cheetah House. A former student of Britton’s, I joined the group in time for a Shabbat dinner. We blessed the challah, then the wine; recited prayers in English and Hebrew; and began eating.
Britton, an assistant professor of psychiatry and human behavior, works at the Brown University Medical School. She receives regular phone calls, emails, and letters from people around the world in various states of impairment. Most of them worry no one will believe—let alone understand—their stories of meditation-induced affliction. Her investigation of this phenomenon, called “The Dark Night Project,” is an effort to document, analyze, and publicize accounts of the adverse effects of contemplative practices.
The morning after our Shabbat dinner, in Britton’s kitchen, David outlines the history of his own contemplative path. His first retreat was “very non-normal,” he says, “and very good … divine. There was stuff dropping away … [and] electric shocks through my body. [My] core sense of self, a persistent consciousness, the thoughts and stuff, were not me.” He tells me it was the best thing that had ever happened to him, an “orgasm of the soul, felt throughout my internal world.”
David explains that he finally felt awake. But it didn’t last.
Still high off his retreat, he declined an offer to attend law school, aggravating his parents. His best friends didn’t understand him, or his “insane” stories of life on retreat.
“I had a fear of being thought of as crazy,” he says, “I felt extremely sensitive, vulnerable, and naked.”
Not knowing what to do with himself, David moved to Korea to teach English, got bored, dropped out of the program, and moved back in with his parents. Eventually, life lost its meaning. Colors began to fade. Spiritually dry, David didn’t care about anything anymore. Everything he had found pleasurable before the retreat—hanging out with friends, playing music, drinking—all of that “turned to dirt,” he says, “a plate of beautiful food turned to dirt.”
He traveled back and forth from Asia to home seeking guidance, but found only a deep, persistent dissatisfaction in himself. After “bumming around Thailand for a bit,” he moved to San Francisco, got a job, and sat through several more two- and 10-week meditation retreats. Then, in 2012, David sold his car to pay for a retreat at the Cloud Mountain Center that torments him still.
“Psychological hell,” is how he describes it. “It would come and go in waves. I’d be in the middle of practice and what would come to mind was everything I didn’t want to think about, every feeling I didn’t want to feel.” David felt “pebble-sized” spasms emerge from inside a “dense knot” in his belly.
He panicked. Increasingly vivid pornographic fantasies and repressed memories from his childhood began to surface.
“I just started freaking out,” he says, “and at some point, I just surrendered to the onslaught of unwanted sexual thoughts … a sexual Rolodex of every taboo.” As soon as he did, however, “there was some goodness to it.” After years of pushing away his emotional, instinctual drives, something inside David was “reattached,” he says.
Toward the end of his time at the Cloud Mountain Center, David shared his ongoing experiences with the retreat leaders, who assured him it was probably just his “ego’s defenses” acting up. “They were really comforting,” he says, “even though I thought I was going to become schizophrenic.”
According to a survey by the National Institutes of Health, 10 percent of respondents—representing more than 20 million adult Americans—tried meditating between 2006 and 2007, a 1.8 percent increase from a similar survey in 2002. At that rate, by 2017, there may be more than 27 million American adults with a recent meditation experience.
In late January this year, Time magazine featured acover story on “the mindful revolution,” an account of the extent to which mindfulness meditation has diffused into the largest sectors of modern society. Used by “Silicon Valley entrepreneurs, Fortune 500 titans, Pentagon chiefs, and more,” mindfulness meditation is promoted as a means to help Americans work mindfully, eat mindfully, parent mindfully, teach mindfully, take standardized tests mindfully, spend money mindfully, and go to war mindfully. What the cover story did not address are what might be called the revolution’s “dirty laundry.”
“We’re not being thorough or honest in our study of contemplative practice,” says Britton, a critique she extends to the entire field of researchers studying meditation, including herself.
I’m sitting on a pillow in Britton’s meditation room. She tells me that the National Center for Complementary and Alternative Medicine’s website includes an interesting choice of words in its entry on meditation. Under “side effects and risks,” it reads:
Meditation is considered to be safe for healthy people. There have been rare reports that meditation could cause or worsen symptoms in people who have certain psychiatric problems, but this question has not been fully researched.
By modern scientific standards, the aforementioned research may not yet be comprehensive—a fact Britton wants to change—but according to Britton and her colleagues, descriptions of meditation’s adverse effects have been collecting dust on bookshelves for centuries.
The phrase “dark night of the soul,” can be traced back to a 16th-century Spanish poem by the Roman Catholic mystic San Juan de la Cruz, or Saint John of the Cross. It is most commonly used within certain Christian traditions to refer to an individual’s spiritual crisis in the course of their union with God.
The divine experiences reported by Saint John describe a method, or protocol, “followed by the soul in its journey upon the spiritual road to the attainment of the perfect union of love with God, to the extent that it is possible in this life.” The poem, however, is linked to a much longer text, also written by Saint John, which describes the hardships faced by those who seek to purify the senses—and the spirit—in their quest for mystical love.
According to Britton, the texts of many major contemplative traditions offer similar maps of spiritual development. One of her team’s preliminary tasks—a sort of archeological literature review—was to pore through the written canons of Theravadin, Tibetan, and Zen Buddhism, as well as texts within Christianity, Judaism, and Sufism. “Not every text makes clear reference to a period of difficulty on the contemplative path,” Britton says, “but many did.”
“There is a sutta,” a canonical discourse attributed to the Buddha or one of his close disciples, “where monks go crazy and commit suicide after doing contemplation on death,” says Chris Kaplan, a visiting scholar at the Mind & Life Institute who also works with Britton on the Dark Night Project.
Nathan Fisher, the study’s manager, condenses a famous parable by the founder of the Jewish Hasidic movement. Says Fisher, “[the story] is about how the oscillations of spiritual life parallel the experience of learning to walk, very similar to the metaphor Saint John of the Cross uses in terms of a mother weaning a child … first you are held up by a parent and it is exhilarating and wonderful, and then they take their hands away and it is terrifying and the child feels abandoned.”
Kaplan and Fisher dislike the term “dark night” because, in their view, it can imply that difficult contemplative experiences are “one and the same thing” across different religions and contemplative traditions.
Fisher also emphasizes two categories that may cause dark nights to surface. The first results from “incorrect or misguided practice that could be avoided,” while the second includes “those [experiences] which were necessary and expected stages of practices.” In other words, while meditators can better avoid difficult experiences under the guidance of seasoned teachers, there are cases where such experiences are useful signs of progress in contemplative development. Distinguishing between the two, however, remains a challenge.
Britton shows me a 2010 paper written by University of Colorado-Boulder psychologist Sona Dimidjian that was published in American Psychologist, the official journal of the American Psychological Association. The study examines some dramatic instances where psychotherapy has caused serious harm to a patient. It also highlights the value of creating standards for defining and identifying when and how harm can occur at different points in the psychotherapeutic process.
One of the central questions of Dimidjian’s article is this: After 100 years of research into psychotherapy, it’s obvious that scientists and clinicians have learned a lot about the benefits of therapy, but what do we know about the harms? According to Britton, a parallel process is happening in the field of meditation research.
“We have a lot of positive data [on meditation],” she says, “but no one has been asking if there are any potential difficulties or adverse effects, and whether there are some practices that may be better or worse-suited [for] some people over others. Ironically,” Britton adds, “the main delivery system for Buddhist meditation in America is actually medicine and science, not Buddhism.”
As a result, many people think of meditation only from the perspective of reducing stress and enhancing executive skills such as emotion regulation, attention, and so on.
For Britton, this widespread assumption—that meditation exists only for stress reduction and labor productivity, “because that’s what Americans value”—narrows the scope of the scientific lens. When the time comes to develop hypotheses around the effects of meditation, the only acceptable—and fundable—research questions are the ones that promise to deliver the answers we want to hear.
“Does it promote good relationships? Does it reduce cortisol? Does it help me work harder?” asks Britton, referencing these more lucrative questions. Because studies have shown that meditation does satisfy such interests, the results, she says, are vigorously reported to the public. “But,” she cautions, “what about when meditation plays a role in creating an experience that then leads to a breakup, a psychotic break, or an inability to focus at work?”
Given the juggernaut—economic and otherwise—behind the mindfulness movement, there is a lot at stake in exploring a shadow side of meditation. Upton Sinclair once observed how difficult it is to get a man to understand something when his salary depends on his not understanding it. Britton has experienced that difficulty herself. In part because university administrators and research funders prefer simple and less controversial titles, she has chosen to rename the Dark Night Project the “Varieties of Contemplative Experience.”
Britton also questions what might be considered the mindfulness movement’s limited scope. She explains that the Theravadin Buddhist tradition influences how a large portion of Americans practice meditation, but in it, mindfulness is “about vipassana, a specific type of insight … into the three characteristics of experience.” These are also known as the three marks of existence: anicca, or impermanence; dukkha, or dissatisfaction; and anatta, or no-self.
In this context, mindfulness is not about being able to stare comfortably at your computer for hours on end, or get “in the zone” to climb the corporate ladder. Rather, says Britton, it’s about the often painstaking process of “realizing and processing those three specific insights.”
Shinzen Young, a Buddhist meditation teacher popular with young scientists, has summarized his familiarity with dark night experiences. In a 2011 email exchange between himself and a student, which he then posted on his blog, Young presents an explanation of what he means by a “dark night” within the context of Buddhist experience:
Almost everyone who gets anywhere with meditation will pass through periods of negative emotion, confusion, [and] disorientation. …The same can happen in psychotherapy and other growth modalities. I would not refer to these types of experiences as ‘dark night.’ I would reserve the term for a somewhat rarer phenomenon. Within the Buddhist tradition, [this] is sometimes referred to as ‘falling into the Pit of the Void.’ It entails an authentic and irreversible insight into Emptiness and No Self. Instead of being empowering and fulfilling … it turns into the opposite. In a sense, it’s Enlightenment’s Evil Twin. This is serious but still manageable through intensive … guidance under a competent teacher. In some cases, it takes months or even years to fully metabolize, but in my experience the results are almost always highly positive.
Britton’s findings corroborate many of Young’s claims. Among the nearly 40 dark night subjects her team has formally interviewed over the past few years, she says most were “fairly out of commission, fairly impaired for between six months [and] more than 20 years.”
The identities of Britton’s subjects are kept secret and coded anonymously. To find interviewees, however, her team contacted well-known and highly esteemed teachers, such as Jack Kornfield at California’s Spirit Rock and Joseph Goldstein at the Insight Meditation Center in Massachusetts. Like many other experienced teachers they spoke to, Goldstein and Kornfield recalled instances during past meditation retreats where students became psychologically incapacitated. Some were hospitalized. Says Britton, “there was one person Jack told me about [who] never recovered.”
The Dark Night Project is young, and still very much in progress. Researchers in the field are just beginning to carefully collect and sort through the narratives of difficult meditation-related experiences. Britton has presented her findings at major Buddhist and scientific conferences, prominent retreat centers, and even to the Dalai Lama at the 24th Mind and Life Dialogue in 2012.
“Many people in our study were lost and confused and could not find help,” Britton says. “They had been through so many doctors, therapists, and dharma teachers. Given that we had so much information about these effects, we realized that we were it.”
In response, Britton conceived of Cheetah House as a public resource. “We’re still in the process of developing our services,” she says. “Lots of people just come live here, and work on the study. Because they’re part of the research team, they get to stay here and listen to other people’s experiences, and that’s been incredibly healing.”
As a trained clinician, it can be hard for Britton to reconcile the visible benefits of contemplative practices with data unearthed through the Dark Night Project. More than half of her patients reported positive “life-altering experiences” after a recent eight-week meditation program, for example. But, she says, “while I have appreciation and love for the practices, and for my patients … I have all of these other people that have struggled, who are struggling.”
“I understand the resistance,” says Britton, in response to critics who have attempted to silence or dismiss her work. “There are parts of me that just want meditation to be all good. I find myself in denial sometimes, where I just want to forget all that I’ve learned and go back to being happy about mindfulness and promoting it, but then I get another phone call and meet someone who’s in distress, and I see the devastation in their eyes, and I can’t deny that this is happening. As much as I want to investigate and promote contemplative practices and contribute to the well-being of humanity through that, I feel a deeper commitment to what’s actually true.”
TOMAS ROCHA is a research associate at the Mind & Life Institute and a doctoral student at Columbia University.
The following is one man’s written reflection on dying. It is worth reflecting on his words to garner a more intimate perspective on ideas of hope and growth when faced with the reality of terminal illness.
Just so you understand: I am dying. I am in the end stage of metastatic prostate cancer, and after six-and-a-half years of close association with the disease, I have another six months to two years to live. That probably sounds exhibitionistic, but I don’t mean it to. Nor am I fishing for pity. Truth is, I’d sooner have your laughter.
Man says, “I’ve been diagnosed with terminal cancer, but I am going to fight it with everything I’ve got.” “My money’s on the cancer,” his friend says. Find me that friend.
When it is incurable, as mine is, cancer always wins in the end, but no one—I mean, no one—wants to hear any such thing. The preferred message in our culture is the sentimental one of hope. Hope is not, however, what the terminal cancer patient needs. Even if you believe in miracles, you cannot hope for one—not the way you hope the car’s skid comes to a stop before the cliff’s edge.
“By definition,” C. S. Lewis writes, “miracles must of course interrupt the usual course of Nature,” but if they were as common as mosquitoes in summer they wouldn’t be interruptions of the usual.
What cancer patients need more than anything is to take responsibility for their disease. From their doctors, from their family and friends, and especially from themselves, they need simple honesty about their condition, their treatment options, their chances. They require exactly what the psychological theorist Karen Horney said the neurotic requires if he is to grow as a human creature: the “square recognition of his being as he is, without minimizing or exaggerating.”
A cure may not be possible, but even in the face of death, moral and intellectual growth is. Susan Sontag was right, in Illness As Metaphor (1978), to object to the Victorian attitude toward consumption—that it was a narrowing of life to a focus upon what is good. There is nothing good about dying of cancer, especially when, as I do, you have four children under the age of eleven and a wife whom you lust after and adore.
But how then do I account for the fact that, every Shabbes after the Shemoneh Esrei, I feel compelled to thank the Creator of the Universe for my cancer? How do I explain the reaction of Bruce Pearson, the uneducated third-string catcher in Mark Harris’sBang the Drum Slowly (1956) who is diagnosed with Hodgkins’s lymphoma at a time when it was incurable? “I am doomeded,” Bruce tells his roommate:
But the world is all rosy. It never looked better. The bad things never looked so little, and the good never looked so big. Food tastes better. Things do not matter too much any more.
Except for the taste of food—chemotherapy makes everything taste metallic, when it does not taste like wet cotton mush—I know what Bruce is saying. The music I listen to, the literature I read when I can barely summon the will to lift a hand, never spoke to me with such finality as it does now.
Is cancer ever a blessing?
No, but only because no human experience, not even marriage, not even the birth of a child, is a sign of God’s favor and a promise of unbroken happiness. Cancer may be a death sentence, but there are many ways to read the sentence. Resignation is only one of them, and a particularly arrogant one at that, because it presumes to know, as it cannot, the outcome in every detail.
But if you are ignorant of the suffering that awaits you when you are first diagnosed, you are equally ignorant of the changes that cancer will work in your thinking and emotional life, some of which may even be improvements in old habits of thought and feeling.
You may, for instance, become more conscious of time. What once might have seemed like wastes of time—a solitaire game, a television show you would never have admitted to watching, the idle poking around for useless information—may become unexpected sources of joy, the low-key celebrations of being alive. The difference is that when you are conscious of choosing how to spend your time, and when you discover that you enjoy your choices, they take on a meaning they could never have had before.
You no longer waste or mark time. You fill it, because now you can see the brim from where you are lying.
“In a sense,” Flannery O’Connor wrote to a friend about the lupus that would kill her at thirty-nine,
sickness is a place, more instructive than a long trip to Europe, and it’s always a place where there’s no company, where nobody can follow. Sickness before death is a very appropriate thing and I think those who don’t have it miss one of God’s mercies.
How could it possibly be merciful of God to reduce you to the hyperawareness, every second of your waking life, that death is relentlessly approaching? Even if it is a knowledge that most other men and women do not have, regardless of what they may like to say, is it knowledge worth having?
You find yourself on a distant planet, alone, with only your own inner resources to fall back upon. No amount of magical thinking or denial will alter your circumstances. You either accept what you have become, and rise above yourself to attend to the others who still need your attention, or you spend your last months in the confinement of self-pity.
In either case, death will come when it comes. The mercy, perhaps even the goodness, is in recognizing the gulf that separates life, which may include terminal illness, and death, which is inevitable, but not quite yet. Whatever your condition, you may always choose life, although you may also choose not to. As Hamlet says, “The readiness is all.”
D. G. Myers is a critic and literary historian who taught for nearly a quarter of a century at Texas A&M and Ohio State universities. He is the author of The Elephants Teach and ex-fiction critic for Commentary. He has also written for the New York Times Book Review, the Weekly Standard, Philosophy and Literature, the Sewanee Review, First Things, Jewish Ideas Daily, the Daily Beast, the Barnes & Noble Review, the Journal of the History of Ideas, American Literary History, and other journals.
Image Used: Tropic of Cancer (2010), by Bill Claps, acrylic on canvas, 63 × 43 in.
Ten years after she began organizing chaplaincy programs in Israel, Cecille Asekoff is seeing her dream come true.
During a 10-day visit to Jerusalem that ended on May 22 Asekoff saw the fruits of her efforts, as executive vice president of the National Association of Jewish Chaplains, to professionalize the ranks of those who minister to the sick, the elderly, and the dying in Israel.
There are now 23 professional spiritual caregivers certified who work in health-care facilities in many parts of the country, “and another dozen or so are in the pipeline,” said Asekoff at an interview in her office on the Aidekman campus in Whippany. “People are receiving pastoral care in every nook and cranny in Israel, and there are more and more of them every day.”
With financial aid from such sources as the Jewish Federation of Greater MetroWest NJ, UJA-Federation of New York, and the American Jewish Joint Distribution Committee, training programs for professional spiritual and pastoral caregivers are expanding in many parts of Israel.
Asekoff, who also serves as director of the Joint Chaplaincy Committee of Greater MetroWest, has been visiting Israel to set up and oversee training programs in many parts of the country for nearly a decade.
The committee and the NAJC, she said, “absolutely” helped make the programs in Israel a success. The training “is not just reading books and writing book reports,” said Asekoff. “It is clinical supervision. It is individual supervision. It is group supervision. It is a spiritual assessment that the trainees conduct on themselves.”
Asekoff acknowledged that at this point only Jews have applied for the training.
“But part of what it means to be a professional chaplain is that you can provide spiritual and pastoral care on a multi-faith level,” she said. “We have a responsibility to train people of various faiths, including Muslims and Christians. We are reaching out to non-Jews on official and non-official levels,” she said, “but to date no one who is not Jewish has signed up for the professional training.”
Those who are being trained, however, are making inroads beyond Israel’s Jews. At Rambam Hospital in Haifa, for example, 50 percent of the patients are not Jewish, said Asekoff. In addition, the Jewish chaplaincy service is part of an international multi-faith committee that accredits programs in the United States and Europe and is working now to adjust their accreditation standards to Israeli culture.
In contrast to America and Europe, Israelis being trained in the field of spiritual and pastoral care are “coming out of the non-clerical world,” she said. “Spiritual care is not necessarily religious, but we do insist that Jewish chaplains have grounding in Jewish literature and Jewish ritual.”
Currently, the chaplaincy training program gets no support from the Israeli government. The hospitals receive government funds, but none specifically allocated to spiritual care providers.
“I’d like to see the field recognized by the government and included in the budget lines of health-care facilities,” Asekoff said. “We have to go and lobby the Knesset and have our message published in the newspapers.”
She remains optimistic.
“I believe professional spiritual and pastoral care chaplaincy is the one thread that can unite all of us with our different ideas, with our different beliefs, with our different colors and sizes. Something we all share together is walking through life and entering people’s lives at critical moments and being able to service them and make their journey more palatable.”