mindfulness writings for http://www.ehospice.com with particular interest for the palliative care community
Over the next ten weeks Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, will be writing a series on mindfulness and how engaging with this process may benefit many areas of the lives of hospice and palliative care workers and patients. In this article, Dr Lück introduces the concept of mindfulness and sets out a plan for the series.
- An introduction to mindfulness, the MBSR programme, and the supporting science
- Perception and appraisal
- Being present
- Responding to stress
- Choices and commitment
- Communication and working with difficulty
- Impermanence and resilience
- Self-care begins here.
Traditionally our five senses are sight, hearing, taste, smell and touch. These senses are mostly to do with experiencing our outer world, our exteroceptive capacities. A sixth sense is often referred to as an intuitive sense, an inner knowing, perhaps beyond our conscious awareness. In this series I wish to explore mindfulness as being that sixth sense, our capacity for greater interoception with conscious awareness, the capacity for choice to perceive and respond to what is going on with each unfolding moment.
Mindfulness is a multi-faceted– and these days much studied– transformative capacity. It is a very old meditation practice adapted to our present day realities. Mindfulness is a capacity we all have: the capacity to be present; to be aware; to notice and observe what we are experiencing in this very moment, without judgment. Jon Kabat-Zinn, Professor of Medicine, Emeritus, and founding director of the Stress Reduction Clinic and Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, defined mindfulness as: ‘moment to moment, non-judgmental awareness, which is cultivated by paying attention’.
Pretty simple stuff, you may say. Just pay attention, here and now, without judging anything to be particularly good or bad. Pretty simple until one spends a few moments with one’s own mind as it is carried on a constant thought stream, commenting on events that are already past or still to come. Pretty simple, perhaps, until one is faced with the distress of pain and suffering, and even with death. Pretty simple, perhaps, until one is faced with loss and bereavement greater than one ever imagined. How then to be present without judging a particular moment that many of us would love to escape?
Very little of our time is actually spent in the intimate space of this unfolding moment to moment experience. Paradoxically, however, much of our own suffering, and that of patients and families faced with life threatening and life limiting illness, comes from a desire to change how the past unfolded into this present moment and to control how the future turns out, and in desiring for the difficulties of this moment to be different to what they are. Mindfulness enables and nurtures our capacity for staying present, for walking alongside our patients and families wherever they may need us to go, with patience, compassion, kindness, and an openness to all outcomes.
Building mindfulness capacity can be protective against compassion fatigue (or empathic distress fatigue as some compassion researchers, such as Tania Singer, now call it). It engages our capacity to resist always looking for the obvious, to wait and listen for those questions that are not yet known at first, to give our patients and families the kindness of time and space, not needing this moment to happen in any particular way.
As a clinician, my saving grace was the fortuitous opportunity to learn mindfulness practices through the Center for Mindfulness at the same time as training in palliative medicine. This has inextricably linked the two for me, and indelibly affected how I practice palliative medicine. The practice of mindfulness has allowed me to sit patiently with many of the daily challenges that palliative care presents. Not just within the clinical space, but also in my work with patients’ families, working as part of a team and interfacing with other health care workers, dealing with ethical dilemmas, issues of access, justice, isolation, vulnerability, death, loss, grief and bereavement. When held within a container of mindful awareness, responding to these challenges takes on a capacity for action that is transformative.
Dr Trish Lück has worked in adult and paediatric palliative medicine in South Africa for the past 13 years, has held the post of medical director at Hospice Witwatersrand and recently team leader of the Paediatric Palliative Care Team, Charlotte Maxeke Teaching Hospital. She has taught mindfulness-based interventions within the health sector, with particular attention to mindfulness interventions as a ‘care for the carer’ programme. She currently resides in London, United Kingdom. Her blog, Living Life with Passion, can be accessed online.
Today continues the ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, sharing how engaging with this process may benefit many areas of the lives of hospice and palliative care workers and patients. In this article, Dr Lück introduces the concept of mindfulness and the MBSR programme, and shares some of the science with links for further reading.
As health care professionals, we live a life directed so much toward the outside activity of caring for others, of keeping up with the busy demands of work, family, even self. We are more human doings than human beings. There is often little time to sit back, reflect on how we even got to this point in our lives. As a health care professional working within the arena of life limiting and life threatening illness, of death and dying, I have become intimately aware that we only have this one life, and that it is finite. I sometimes joke with my patients that we all have a terminal illness– It’s called life! Many of us live as if that is not true, and we get frustrated perhaps when our patients and their families sit with denial of a diagnosis that brings this awareness much closer. Perhaps it is time to look a little closer, a little more intimately into our own awareness of how this life of ours is unfolding.
For me the MBSR programme, or other mindfulness-based interventions, offers such an opportunity. An opportunity to enquire deeply into what this life of ours truly is about. An opportunity to change habits of being or reactivity, of feeling under pressure by all that comes our way, bidden and unbidden. Mindfulness supports our capacity to show up and to be present, not just to others that we care for, but also to ourselves. To turn toward what is difficult in our own lives with kindness and compassion, and to not react to an ever present urgency that often has us try to fix or turn away.
The MBSR programme was developed by Dr Jon Kabat-Zinn at the University of Massachusetts Medical School in 1979. Dr Kabat-Zinn started the Stress Reduction Clinic and offered this programme to patients with difficult pain and chronic illness, when standard treatment was not helping. The curriculum “features the cultivation of mindfulness of mind states and body states including, in particular, awareness of reactive emotions, as well as how to deploy specific strategies to respond mindfully rather than reacting reflexively when triggered, and even more so if these emotions tend to linger and color one’s longer term experience, actions, and relationship, as they so frequently do” (Jon Kabat-Zinn, Foreword to: Teaching Mindfulness by McCown, Reibel, and Micozzi).
Even though mindfulness has been found through research to: engage our capacity for more skillful decision making, decrease burnout among clinicians, support the immune system, improve wellbeing in a multitude of illnesses, decrease anxiety and depression relapse, impact the rate of our aging, enable more engaged listening and speaking capacities, one of the things that mindfulness is not, is that it is not a purely cognitive process. Even though it seems that mindfulness is everywhere at the moment (on the front page of Time Magazine this week, in various newspapers and magazines, even in the UK Parliament and US Congress) it is not a process that can be engaged with through only reading and talking about it. Mindfulness at its deepest essence is a way of being, cultivated through experientially engaging with it. All will not be revealed in this first article, as it is not in the first MBSR class, but will be an ongoing interface with curiosity and the invitation to fully engage with what is going on in your life at this very moment. And perhaps in fully engaging with your own life, you may find a greater capacity to engage with that of the patients and families you serve.
Facilitating a session for the palliative care team at Chris Hani Baragwanath Hospital in Johannesburg through a brief body scan (see next week’s article on short meditations), we ended with some time settling into the heart space itself. Noticing the beating of the heart. Noticing the resting of the heart. In the ensuing inquiry, one of the home care sisters shared her surprise: “I also have one of those organs!” she said, hand over her heart, strongly clasping at it, eyes wide with wonder. “A real heart!” How easy it is to live a distance away from our own bodies, to not really engage with our own physicality until it perhaps demands our attention through illness or injury? The gift of mindfulness is to change this habit. To turn toward a greater knowing of this body we inhabit throughout each day, and turn toward a noticing of its wondrous capacity, and how– so much more than we appreciate– it is amazingly functional and beautiful.
Here are two short meditation exercises for you to practice:
- Sit. Notice. Breathe.
For a few brief moments right now, put down any pencils, papers, and once you have read this, stop looking at the screen. Sit back in your chair, or wherever you find yourself, allow your body to be supported upright as best you can. Notice for now the sensations of movement of your own breath. Can you notice movement of air at the nostrils; movement of the ribcage as breath enters and leaves the lungs; movement at the belly as it rises with each in breath, falls with each out breath, expanding the diaphragm? There is no need to change or judge the rhythm of your breathing at all. For now just engage a sense of curiosity about each breath, this breath, and the rhythm that it already has in this very moment.
2. Drink tea, eat mindfully.
This week as you spend time eating and drinking, bring attention to this activity. Notice the taste of the drink and food in your mouth. Notice the aroma, the colours, the flavours, the differing sensations of textures on your tongue. Notice the movement involved in bringing the food and drink to your mouth, the movement of the face, of the lips, of the swallowing, and any other sensations that you may be aware of. Engaging a kindly curiosity of what it is you are already doing. For now not needing to change any of it.
References and further reading
Ludwig, D., Kabat-Zinn, J. (2008). Mindfulness in Medicine. JAMA, 300(11). pp: 1350-1352
Krasner, M., Epstein, R., Beckman, H. et al. (2009). Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among primary care physicians. JAMA, 301(12). pp: 1284-1293
Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M. A., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K., & Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation.Psychosomatic Medicine, 6. pp: 564-570
Carlson, L. (2012). Mindfulness-Based Interventions for Physical Conditions: A Narrative Review Evaluating Levels of Evidence. International Scholarly Research Network (ISRN), 2012
Williams, J., & Kuyken W. (2012). Mindfulness-based cognitive therapy: a promising new approach to preventing depressive relapse. British Journal of Psychiatry, 200. pp: 359-60
Jacobs, T., Epel, E., Blackburn, E. et al. (2011). Intensive meditation training, immune cell telomerase activity, and psychological mediators. Psychoneuroendocrinology, 36(5). pp:664-68
Mindful magazine (Monthly mindfulness magazine)
Mindful experience (Mindful Research Guide with monthly updates).
Today is the third week of our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, exploring perception and appraisal in everyday palliative care moments.
One of my very first hospice patients that I was called to visit at home many years ago was a challenging engagement with age, gender, culture, religion, and more. He was a young Muslim man, bedbound now due to a spinal tumour, being tenderly cared for by his mother.
We had many communication bridges to cross before I could be of any real assistance to him, many moments of just sitting quietly together, through the at times awkward silences, as I waited for what was needed beyond the obvious of pain control, advice for his mother, and time spent drawing pictures with his little sister.
Eventually after many visits of patient silence and growing trust, he asked the question that had hung in the air for so long. “Please, tell me again, about my tumour, and what it means.”
And so the conversation started. The inquiry into what he knew, how much he wanted to know, the full discussion and eventually release into the truth that he would die with this. What remains with me is not so much the discussion and his subsequent death, but his response to very first question I asked him that day. A response that to this day informs every encounter I have with a patient and their family. I asked him: “How do you want me to tell you?” And his only response was: “Gently,” having previously been at the receiving end of a very callous and harsh disclosure process. My perception of this young man, and for that matter, any young man, did a complete rotational shift and with it my approach to all subsequent difficult conversations.
Perhaps it was an obvious one; there is no other way to have such a difficult conversation, other than gently, but having a paralyzed, bedbound, dying young man name it so openly for me, shifted my world. It could only do so because I had been paying attention and been open to what he needed. I had not prejudged what it was that he needed me to say.
We all probably have had the experience of watching clouds drift across the sky changing their form and imagining various images and shapes in them. Everyone has a different idea of what the cloud looks like, and this is a little bit like our own life experience. We all have a different opinion of what difficult is, what stressful is, what it is that we struggle with, and as such really can not know the experience of the other, other than offering our presence, our kindness and our willingness to walk the road beside them. This applies both for those we care for and for ourselves. Stress, as we understand it, is not what happens to us, but what happens anyway and how we respond to it.
Our capacity to stay present for and have a greater understanding and awareness of our own experience enables us to have greater capacity to stay present for others and allow their experience to be held in a way that can assist them on their difficult journey.
You may have noticed last week with the short meditations as you paid attention to breathing or to eating and drinking, that your mind tended to wander off on its own to other thoughts, memories of past events, planning the future, perhaps discomforts of the mind and body, and before you knew it the breathing, the eating, the drinking was forgotten until your remembered anew: ‘Oh..! breathing, eating, drinking…’ and you guided your attention back to what you were engaged in. For now that is the practice, noticing as your attention wanders and as soon as you notice, your attention is present again in this moment. It is present to choosing to attend back to the breathing, the eating, the drinking. This practice grows our capacity for patience and asks that we look at each new moment with curiosity and wonder, letting go of any preconceived idea of what this moment should look like, allowing it to show up just as it is, not needing to embellish any of it, not needing it to be anything in particular other than being intensely curious about how it actually is. You bring a sense of kindly curiosity to that enquiry. You might be surprised to find that this moment that perhaps seemed to take a prejudged quality, when engaged with mindfully, holds a multitude of moments that cover the full spectrum from pleasant to unpleasant, and even neutral.
So as you move through this next week, notice your moments of deciding an outcome before it has already happened, cultivate patience, curiosity, and kindness to whatever this moment may be unfolding for you. Continue to take a few moments to notice and follow your breathing through the day, noticing as your mind wanders to thoughts, other body sensations, emotions, returning as soon as you notice, to being aware of the moment of breathing, exhaling, inhaling.
Here are two short meditation exercises for you to practice:
For about 10 minutes a day, over the course of this next week, sit in a quiet space, comfortable in a chair or on the floor. If you wish, you can allow your eyes to close or keep them softly focused ahead of you. Begin with settling into breathing as you have been doing this past week. Noticing breathing in and breathing out, either at the nostrils, chest region, or abdomen. Noticing the movement of air, the rise and fall of the ribcage, diaphragm and abdominal wall. Then slowly allow your attention to shift to the feet, the legs, and notice sensations in this area of the body: front and back surfaces, external and internal sensations, contours, creases, clothing, air, temperature, pressure, discomfort, without needing any of these sensations to change. Gradually shift your attention up through the body: through the lower legs, the knees, the upper limbs to the hips joints and on to the torso. The pelvic area, the back, the abdomen, the chest region, the shoulders and arms from fingertips, lower arms, elbows, upper arms, shoulder joints, gradually moving onto the neck, the face, the head, paying attention to all the small areas of shift and change in sensation. At times you may not have any awareness of sensation or be aware of discomfort, all of this is okay, and as best you can, just notice what is present without needing that to change. Attending to all sensations with gentleness, openness, and kindness, and if needing to move, doing so with engaged choice and awareness. Ending the meditation exercise with becoming aware of the body in its completeness and wholeness, all of the individual areas being part of the whole that make up this body, your body, so much more of it being okay than perhaps you have noticed before.
For this week chose one routine activity you do every day and attend to doing it with intentional kind attention. Noticing the movement, the sensations, the thoughts and emotions that may be present. Be intimately engaged with what you are attending to and curious about a perhaps habitual activity to which you generally give little thought – showering, brushing teeth, washing dishes, or anything else you may choose for this activity – noticing movement, flow of water, touch of air, what you do that you normally don’t notice so intently.
This week, week four, of our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, we explore the theme of Being Present.
“Be courageous enough to remain alongside families ‘into that place of unknowing'”. – Words spoken by Sister Frances Dominica this week during her opening address to the Inaugural International Children’s Palliative Care Network Conference in Mumbai, India, sharing her story of opening the first children’s hospice, Helen House, in Oxford in the UK. I wonder how many of us feel we have this courage in our daily caring for patients with life limiting and threatening illness.
How often each day do we feel able to walk alongside families into the ‘place of unknowing’? Do we know when it arises? Can we recognise when we are being present to that moment that demands we remain alongside families we care for into that place of unknowing, often a place of fear, uncertainty, pain, suffering, and distress. Mindfulness helps us turn toward each moment, no matter the difficulty, and stay present for ourselves and for our patients and their families, and their very particular needs that only arise when we make space for the unknown; the unknowing of this moment as it unfolds.
Courage seems to be the theme today. The theme of what is demanded of us when we dare to be present for whatever arises in our daily lives of being present to ourselves as well as to the families we serve. Not only spoken to by Sister Dominica in her opening address, but also raised in discussion of an upcoming talk I am being asked to give and how being mindful is not about creating a wonderfully rosy life, but is about engaging with the life we already find ourselves living with courage and conviction. Cultivating the capacity to be present with the– at times extremes of– difficulty and not turn away from the suffering and distress that may be present. This takes courage indeed.
If you have been following these weekly articles the past three weeks and practising being with breathing, eating, attending to a daily routine task, and engaging with the body scan with curiosity and kindness and patience, you may have started to notice moments opening up that have felt unburdened by constant thought or difficulty, but just were present– even at times in the midst of difficulty itself. That once we start paying attention to the small unfolding moments and allowing them to be just as they are, there are perhaps many more moments of wonder that we may have otherwise missed.
One evening a couple of years ago I was called out by a young family, new to me, in distress, who having returned home precipitously from a brief holiday as their child’s pain had increased dramatically, could not coax him out of the car once home and back inside the house, who refused to have anyone else come, and so they patiently waited until I arrived to render the hoped-for miracle. Distressing it was for all involved, a fearful pain-ridden child huddled in the back of the car, anxious adults all around, a moment of anxious unknowing for all of us.
Climbing carefully into the back seat of the car, I surrendered to that place of unknowing, gently inquiring, reassuring, problem solving, medicating, waiting for effect, and during that time even sharing some silly laughter at the expense of all of us crowded in and around the back seat of the car.
We were preparing for the moment of choice, the moment of action, of difficulty we all knew would come. And in the moments of staying with the unknowing, with the difficulty, we too could be open to the brief moments of joy, moments that might have been easily missed, the glimpses of laughter that made the unbearable moments to come bearable, able to be held and turned toward, and then let go of once it had passed. Moments of courage to remain alongside the unknowing and be present for what was needed.
During the second and third week of a traditional MBSR programme, we pay attention to the aspects of our own body and mind that constantly comment on our present moment experience– commentary and critique that often keeps us lodged firmly into either the past or the future with little space for being present to the only moment that we have to make any choice. This is the only moment we have for affecting any change in our lives. The capacity of mindful presence enables our capacity to be present, to respond with awareness rather than the reactivity of habit, and in that moment gives us the gift of choice to decide. Mindful presence is about knowing this moment, however it shows up, whether pleasant or unpleasant, and in the noticing, we may become aware that even in the most difficult moments there can be moments of joy.
Often we only notice our moments in hindsight. Remembering them to be either pleasant or unpleasant. Realising perhaps too late how wonderful the moment was, rarely having a present moment awareness of what a pleasant experience feels like in the moment that it is happening. So for this week, pay attention to noticing pleasant moments. Noticing the moment at the very moment of the experience. Being curious it you can catch the moment of having a pleasant experience as it arises, just as it is. Noticing the body sensations, the emotions that arise, thoughts that accompany the moment. Seeing if you can catch this moment as it arises and unfolds, and then noting it and describing it. Keeping a daily record if you wish, one pleasant moment noticed each day.
Continue also to spend moments noticing and following your breath, eating and drinking with awareness, practicing a ten-minute bodyscan, and doing one daily habitual task mindfully. Cultivating patience, kindness, curiosity, and a capacity to be with and turn toward this moment, however you may find it to be.Be patient toward all that is unresolved in your heart And try to love the questions themselves Like locked rooms and like books that are written in a very foreign tongue Do not seek for the answers that cannot be given For you would not be able to live them And the point is to live everything Live the questions now And perhaps without knowing it You will live along some day into the answers By Rainer Maria Rilke
Mindfulness – our sixth sense: responding to stress
This week, week five, in our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, we explore the theme of Responding to stress.
How we respond to stress is infinitely individual and infinitely dependent on our perceptions of what for us is stressful.
At its essence the MBSR was developed as a stress reduction programme. The first classes started in 1979 at what was then called: The Stress Reduction Clinic at the University of Massachusetts Medical School in Worcester. This programme was engaging with cultivating a way of learning to respond to the many stressors in our lives including: pain, suffering, chronic illness and many varied difficult life conditions, rather than indulging the reactivity of the mind that is the result of habitual ways of being. How we respond to stress, however, is infinitely individual and infinitely dependent on our perceptions of what for us is stressful. None of us have the two same definitions. We may have some tacit agreement that a certain level of distress and suffering is stressful – pain, illness, emotional and spiritual distress, dying, and death, but we cannot be specific on how the individual themselves responds to that stress. This is highly personal and unique. What I may find stressful, another person may not be perturbed by. So what is it that makes the difference? I could go into more depth and detail, but enough perhaps to say that how we respond to stress depends on our own history, experiences, genetic make up, cultural and social environment, our experiences of change, trauma, ability to cope with difficulty, as well as habitual reactivity. Herein resides the crux of stress reactivity, our habitual reactivity, our habitual way of defaulting to automatic pilot without engaging choice in the moment. Once we become aware of what it is that causes our body and mind to react to stress with a cascade of hormones that cause changes in breathing, heart rate, blood pressure, gut activity, mental function and more, we have cultivated some capacity for choice. This is the capacity which is developed through mindfulness: The capacity to be aware of what causes us stress, to examine it with curiosity with no attachment to changing the outcome, with kindness and compassion toward our own very human experience. The capacity to trust that in this moment we are okay, no matter what is happening. In the past week, if you have been following this series and doing the short meditations and practices, you will have been paying attention to pleasant events. You will have been noticing if you can catch the moment of the experience. Being aware of the event as it unfolded, the sights, the sounds, the sensations, the smells, the emotions, the thoughts, the interaction of what happened, and through this noticing being fully present and engaged with awareness of ‘pleasant’. Even if it may have been a fleeting moment of smelling a rose on Valentine’s Day, eating a piece of chocolate, or drinking a cup of tea, allowing your noticing and senses to be fully engaged in experiencing the pleasant moment. We so often allow the small moments to rush past and give the unpleasant moments more prominence. So in the exercises, we have been reflecting for a moment here on one of these pleasant moments and all that was evoked at that time. The task that will be set for this week is noticing the unpleasant moments: allowing them to unfold with kindness and curiosity to the experience that is labeled in your mind as being unpleasant. Seeing if you can be curious as to what this is, what makes it unpleasant, how does the body feel, what are the sensations, where, what are the accompanying thoughts and emotions? Noticing perhaps changes in breath, temperature, heartbeat, skin sensation, and the racing, seemingly knowing mind of how this particular unpleasant event reinforces a habitual pattern of mind. Or does it? Perhaps take some time to bring kind curiosity and attention to what is already here without making up a story about how it is.One little girl who showed me the meaning of responding rather than reacting to the certainty of death was a little girl with leukaemia from one of our northern neighbors in South Africa. Going back home to the certainty of very few days she chose to engage with the remaining days she had with laughter and joy, with reconnecting to her faith in the afterlife and the love of her god with dreams and stories, and being nurtured by the care of her loving family. Even though in the end the safety net of medication and medical support we had tried to set up did not work as well as we had hoped, she did not dissolve into despair or fear but continued to chose to be present to life with the joyful heart she had brought to all of her 14 years, showing me how it was possible to not be caught in reactivity of fear and difficulty and distress, even in the face of certain death.
So this week be curious about what you may be labeling as an unpleasant event, how this may be stressful for you, what your experience is in this moment– body sensations, thoughts, emotions– noting one event per day down in your journal if you wish.
Continue to work with previous short practices: being with breathing, eating, attending to a daily routine task, and engaging with the body scan with curiosity and kindness and patience and add in this week a short walk meditation practice.
Spend a few moments attending just to walking. This can be outside or inside. Where ever you feel comfortable.Chose a short particular lane (of your own making) in which to walk. Let your arms be soft, either by your side or held gently in front or behind your body. Allow your eyes to have a gentle focus a short distance in front of your body. Noticing as you walk the sensation of walking in your body, your legs, your feet. Notice the contact and connection made with the surface you are walking on, either barefoot, stocking-footed or with shoes. Notice the action of walking as you are walking – lifting – shifting – placing – lifting – shifting – placing…Noticing breathing, thoughts, other sensations, emotions arising in the moment. If it is helpful, naming these in your head, and letting go of needing to make a story of any of them, returning your attention gently each time to simply noticing walking.
This week, week six in our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, we explore the theme of choices and commitment.
Having now come to week six of ten in this series I am curious, if you have followed the previous five weeks, how you have been working with the various options of choice and commitment. Being mindful, attending to the moments of the day with kindness, curiosity, patience, with a perhaps greater acceptance of what is already here, without needing these moments to change, be different, or forcing a desired outcome, opens up potential space for choice.This is a space that can be stepped into with attention and skill, with a flexibility that acknowledges all the possibilities laid out. With cultivating mindful, curious, kind attention and care through the practice of the various meditations – eating, sitting, bodyscan, walking, as well as noticing the labels we attach to what we perceive as being pleasant or unpleasant events with the accompanying unfolding sensations, emotions, and thoughts that may occupy our mind body space – we are presented with some awareness that the moment opens up capacity for choice, capacity to make a decision in how to proceed, capacity to make a commitment to action or inaction.As Goethe tells us, commitment takes boldness and boldness has genius, power and magic in it. It is not until we completely commit to a particular path that we let go of the ‘what ifs’ and ‘should haves’. As Robert Frost melancholically rues in his poem:
The Road Not Taken
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveler, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
Then took the other, as just as fair,
And having perhaps the better claim,
Because it was grassy and wanted wear;
Though as for that the passing there
Had worn them really about the same.
And both that morning equally lay
In leaves not step had trodden black.
Oh, I kept the first for another day!
Yet knowing how way leads on to way.
I doubted if I should ever come back.
I shall be telling this with a sigh
Somewhere ages and ages hence:
Two roads diverged in a wood, and I –
I took the one less traveled by,
And that has made all the difference.
How we make choices has much to do with our capacity to stay with ambivalence. Ambivalence by its very nature makes us uncomfortable. We would like to know and be sure. But ambivalence is the inherent nature of illness, of suffering, of death. Ambivalence is the constant bedfellow of our work with those that walk this path every day. And in that ambivalence, our capacity to make choices in the face of not knowing may become our greatest resource. And that action may be the choice to do nothing, to just sit and be present, fully present.
Last evening my own teenage daughter, given a difficult decision she needs to make, confessed how she struggles with such decisions and spends so much time once the decision has been made wondering about the other and whether she had made the right one. I don’t think she is alone in this angst. Ultimately the road we take is the one that makes the difference and determines the path we tread, as we cannot know what it would have been to take the other. At times, however, we find ourselves spending an inordinate amount of time wondering about the other road and maybe missing the actual road that we are on. Mindful capacity allows us to turn to the experience of this moment and let go of the moments of the past, the future or the ‘might have beens’.
So this week as you continue with the meditation exercises, continue to work with pleasant and unpleasant moments. Spend time eating, breathing, sitting, walking with mindful attention and notice the choices you are making. Notice if you slide into habitual reactivity and action or to being or not being, or if you can be aware in this moment of what arises, give it some moments of kind mindful attention, notice what arises in your fieldscape of sensations, emotions and thoughts, and then proceed with boldness and choice. Perhaps asking yourself a simple question: “What is called for now?”
This week, week seven, in our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, we explore the theme of communication and working with difficulty.
Without this deep listening, we might have missed that this doctor was a specialist in her own right from a foreign country, not recognised yet as one in this country where she was working. Her own resentment and ambivalence at not being trusted with care became part of what was present in speaking her truth. We were able to agree on a plan of action that worked even with the possible misunderstandings of care that existed, and were able to ensure that this patient died a peace-filled, pain-free death very shortly thereafter. All this was achieved through the simple capacity of turning toward the communication difficulty rather than away from it.
So as you go through this next week, in addition to continuing to attend mindfully to breathing, eating, sitting, walking, daily tasks, perhaps spend some time noticing how you communicate with others, and how you communicate with yourself. Communicating not just through verbal interaction, but also through body language, writing, texting, and how you present yourself in public and private spaces, inwardly and outwardly. Noticing if you rush to communicate what is uppermost on your mind or if you can perhaps pause, relax, open to what is here, listen deeply first and then only speak your truth that emerges for this very moment. Try it. Remain curious of what this way of communicating may present for you. As you do so I will be in the middle of a nine-day silent retreat, not communicating other than with myself silently alongside others, and wondering how you are in the midst of this moment.
Today is the eighth week of our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, exploring impermanence and resilience in everyday palliative care moments.
Life is anything but permanent, as many of us who work in the area of life-threatening illness and dying know, and it demands of us that we show up with compassion and resilience for our everyday encounters. My understanding of resilience includes the capacity to be present and to feel okay with what arises for us every moment of each day, and to meet it with flexibility of spirit and response. This capacity of resilience can be cultivated to enable us to meet life in all its complexity.I have spent the past nine days at a small retreat centre at the base of a mountain in the southern Drakensberg Mountain Range in South Africa. This particular mountain is revered as sacred in both San and Zulu traditions for its capacity to bring forth rain. Cave paintings depict the San elders performing rain-making ceremonies. Zulu rituals to pray for rain take place at its base in times of scarcity.During the nine days I sat in retreat, we did not suffer from a lack of rain and at times it was hard to believe that there was even a majestic mountain behind the curtain of mist, rain and cloud. But the mountain did appear at times and the last two days it shone with clarity against a deep blue sky between torrential downpours, only to be swallowed up again by the mist as we drove away. What I intimately learnt from sitting under this mountain during the weather patterns that swirled around it as well as through my heart-body-mind-space, was a deep knowing and a felt sense for how impermanent the weather patterns of our personal as well as our physical environments are.
The capacity to be with what presents itself in our heart-body-mind-space, like weather swirling around a steady ever-present mountain, helps us to understand how a greater capacity for mindfulness can impact how resilient we feel in our day, our life, and our work. How we perceive and understand events, or for that matter, fail to perceive or understand them, often determines how we respond to them.
Most of us have an understanding that we have little control over external events, such as the weather, but have some capacity to determine how we respond to them. In 1979, Suzanne Kobasa looked at how personal dispositional factors influenced whether we interpret a stressful event as threatening or not. She described three psychological aspects: control – whether we feel we can impact some areas of our lives positively; commitment – how engaged we feel with our daily lives; and challenge – how much we feel we can effect change on our life circumstances. She related these factors to ‘Stress Hardiness’, which is understood more and more as an important factor in psychological resilience, our capacity to be resilient even in the face of great challenge.
Our growing capacity to be with all our moments as they arise, with patience and kindness, supports our capacity for presence, for resilience, for being mindfully engaged in every moment. A capacity to be able to engage with the positive moments that arise in our lives, to be engaged with what we are doing, and to see the difficulties that may arise as challenges rather than problems. The simple exercises: staying with your breath, body scan, eating, walking with mindful presence, can be supportive of engaging with a capacity to recognise each moment as it arises and even in the face of impermanence, illness and death, to be stress hardy and resilient.
Today is the ninth week of our ten week mindfulness series by Dr Patricia (Trish) Lück, a palliative care physician and facilitator of mindfulness-based stress reduction (MBSR) programmes, exploring self-care for the healthcare professional in everyday palliative care moments.
Many, if not all, of us struggle with caring for ourselves. This seems to be a common affliction, and especially so for health care professionals caring for the most vulnerable in our society. It seems to be a paradox that we need to first care for ourselves well before we are able to care better for others. Indeed being of service can be a healing part of our day and give great meaning to our lives. In giving we often find that we receive so much more. If, however, the giving and being of service goes beyond the boundaries of our own capacity without us being fully aware of this, we are in danger of becoming run down, suffering compassion fatigue and burnout and even not being able to manage our day to day interactions.It is telling that this is an issue even for me, despite the fact that I have widely lectured and given workshops on precisely this topic. I was struck recently in conversation with my daughter that after so many years of doing the traditional required amount of children’s ‘bee’ projects, I never really considered that the bee was not just playing a role in collecting nectar for the hive and in making the honey, but that the bee needed to feed itself along the way first to sustain its own energy capacities. It felt like a light bulb moment: so very simple, but one I had consistently missed for many years.
Self-care can be as simple as taking a few more purposeful moments in the day to eat, drink, walk, sit, hold conversation, listen deeply, exercise, wash and sleep with greater awareness. Taking time to be with the tasks that need doing each day in the small things we already do that take care of our bodies, minds, work spaces and families. The capacity to allow mindful awareness to arise within the moments of our day enables our capacity to connect with what is needed now and not to be stuck in an automatic mode of ‘just carrying on’ no matter the need. The capacity to stop, take a few breaths, a few moments, to reflect and observe what is happening and then proceed can be a valuable pause inserted into the unfolding of each day.
Michael Kearney, in his excellent article on self-care of physicians at the end of life, identifies some simple measures that could be protective against burnout. These include mindful meditation, reflective writing, supervision and mentoring, sustainable workload, promoting feelings of choice and control (as discussed in last week’s article), a supportive work community, fostering communication and self-awareness skills, practicing self-care and mindfulness based stress reduction for team.
For me it begins with becoming aware of how we care for ourselves already each day and pay a little more attention to that – and especially how we communicate with ourselves and others, how much kindness we bring into each day. Peirro Ferrucci in his book: The power of kindness states that: “Attention is the medium through which kindness can flow. No attention, no kindness. And also no warmth, no intimacy, no relationship.” Attending to ourselves with kindness, love and care can be the greatest gift we offer those we attend to in our daily lives. Mindfulness can be a radical act of love and kindness in and of itself. Being with whatever arises in this moment, without judging how it should be – or how we should be –with heart and with warmth and with kindness, is a moment of self-care purely through the simple act of showing up for our lives with kindness and care.
Finally, I wish to remind ourselves that we can find self-care and meaning and vision in the very presence of our daily work. Often we neglect that this can be a source of self-care in and of itself, that it is what we have chosen to pursue each day and to continue to engage with every day. As Rachel Remen, doctor, healer and author, states: “No question that the medical system (in the USA) is seriously broken, but Medicine itself is not. Even on the most stressful and pressured of days there are moments in which we can experience something else, moments in which we connect to people on a very intimate level and make a difference to them and they to us. Times when, despite everything, we experience compassion, give and receive love, ease suffering and fear and are profoundly trusted. Instances when the greatness and courage of an ordinary person is suddenly revealed and we know ourselves to be in the presence of a hero. Or we recognize that we ourselves are heroes. No question that these experiences are brief, but they happen daily. And often they are life-giving – like taking single breathes of pure oxygen in the middle of a deep-water dive. There is a deep river of meaning that runs through the work of every health professional. It can sustain us in difficult times.”
So as you continue into the next week, take some time to sit, breathe, walk, be, and allow – in those moments of connection and reflection and mindfulness – to be fully present to the magnificence of your life. Take some time to STOP, engage in mindful meditation and reflective writing and engage with kindness and care with yourself, your patients and your own families.
S – Stop
T – Take a breath
O – Observe, pause, take a few moments to consider what is happening now. What are you feeling, thinking, what sensations are present. What is needed now.
P – Proceed with full awareness and no longer with the automaticity of the habitual mind but with the capacity to respond with awareness of knowing this moment fully.
Kearney, M.K., Weininger, R.B, Vachon, M.L.S. et al. Self-care of Physicians Caring for Patients at the End of Life: “Being Connected … A Key to My Survival” JAMA. 2009; 301(11). pp:1155-1164